Congenital Synostosis of the Knee: Long-term Outcomes of Limb Reconstruction Surgery.

BACKGROUND: Congenital synostosis of the knee is a rare condition with limited data on treatment options and outcomes. This study reports clinical findings, treatment approach, and surgical/clinical outcomes for congenital synostosis of the knee. METHODS: An institutional review board-approved retrospective review of patients with congenital synostosis of the knee presenting to 2 institutions between 1997 and 2021 was performed. RESULTS: Eight patients (13 knees) with a median follow-up of 11.3 years (3.3 to 17 y) were included. Seven patients had associated syndromes. Patients presented with an average knee flexion deformity of 100° (range 60 to 130°) and delayed walking ability. Seven patients had associated upper extremity hypoplasia/phocomelia. The average age at the index surgery was 4.3 years (range 1.2 to 9.2 y). Synostosis resection with gradual deformity correction was performed in most patients. An attempt was made at a mobile knee in some patients, but all went on to knee fusion. Mean flexion deformity at final follow-up was 11.6° (range: 0 to 40°) and 5 limbs were fused in full extension. Mean limb length discrepancy at final follow-up was 6.8 cm (range: 0 to 8 cm). All patients maintained their improved ambulation status at final follow-up. Twenty-two complications were identified. CONCLUSIONS: Reliable correction of the deformity associated with congenital knee synostosis was achieved at a median follow-up of 11 years. Importantly, all patients maintained their improved ambulation at final follow-up. This is the largest study on patients with congenital knee synostosis and outlines a reconstructive approach to improve ambulatory status. LEVEL OF EVIDENCE: Level IV.

Treatment failures and complications in patients with Blount disease treated with temporary hemiepiphysiodesis: a critical systematic literature review.

This systematic review sums up the state of knowledge about complications and reasons for failure when children with Blount disease are treated with temporary hemiepiphysiodesis. Twelve studies meet the inclusion criteria. The main reported obstacles were under correction and the poor predictability of the amount of correction that was obtainable. Obese patients with severe deformity are the most challenging groups of patients in the treatment of angular deformities. Patients with Blount disease require a careful evaluation regarding the deformity, age, body weight, and social background to reach the optimal treatment strategy. If hemiepiphysiodesis fails, osteotomy remains the preferred salvage procedure. LEVEL OF EVIDENCE: IV.

Symptomatic Os VesalianumA Case Report and Review of the Literature.

Os vesalianum is a rare accessory bone located proximal to the base of the fifth metatarsal in the peroneus brevis tendon. It is a radiographic diagnosis and mostly an asymptomatic incidental finding with a reported prevalence of 0.1% to 0.9%. Only 11 symptomatic cases have been described in the literature. Surgical therapy has been reported with good outcome in adults, whereas recurrence may follow excision during skeletal growth. We report a case of a 19-year-old girl with chronic weightbearing pain proximal to the base of the fifth metatarsal of her left foot. She first experienced exacerbated pain on increased loading when she started professional training as a shop assistant. Because several months of nonsurgical therapy failed, the decision was made to surgically excise the accessory bone from the peroneus brevis tendon via a longitudinal incision and a simple tendon-to-tendon reconstruction. Postoperative treatment consisted of using a walker to avoid weightbearing for 6 weeks, followed by a gradual return to full weightbearing as tolerated. At final follow-up, the patient was fully asymptomatic and was able to return to work. Citing this case, this article discusses differential diagnoses and treatment options for os vesalianum.

PRECICE® magnetically-driven, telescopic, intramedullary lengthening nail: pre-clinical testing and first 30 patients.

INTRODUCTION: Femoral/tibial lengthening with a telescopic, magnetically-powered, intramedullary nail is an alternative to lengthening with external fixation. METHODS: Pre-clinical testing was conducted of the PRECICE in a human cadaver. A retrospective review of the first 30 consecutive patients who underwent unilateral lengthening was also conducted. Nail accuracy was obtained by comparing the amount of nail distraction to the final bone length achieved at the end of the distraction process. Relative standard deviation of accuracy was used to calculate nail precision. RESULTS: Devices performed successfully in a human cadaver. Thirty consecutive patients (10 females, 20 males; mean age, 23 years) with limb length discrepancy (LLD) were followed an average of 19 months (range, 12-24 months). Etiology included congenital shortening (14), posttraumatic deformities (7), Ollier disease (3), osteosarcoma resection (1), prior clubfoot (2), hip dysplasia (1), post-septic growth arrest of knee (1), and LLD after hip arthroplasty (1). Twenty-four femoral and eight tibial nails were implanted. Mean preoperative lengthening goal was 4.4 cm (range, 2-6.5 cm); mean postoperative length achieved was 4.3 cm (range, 1.5-6.5 cm). Average consolidation index was 36.4 days/cm (range, 12.8-113 days/cm). Mean nail accuracy was 97.3% with a precision of 92.4%. Average preoperative and 12-month postoperative Enneking scores were 21.5 and 25.3 (p < 0.001), respectively. The preoperative and 12-month postoperative SF-12 physical and mental component scores were not statistically different. Nine complications (nine limb segments) resolved: two partial femoral unions, two suspected deep vein thrombosis (DVT), one delayed tibial union, one fibular nonunion, one peroneal nerve irritation, one knee joint subluxation, and one confirmed DVT. Twenty-nine (91%) of 32 limb segments achieved successful bone healing without revision surgery. DISCUSSION: Limb lengthening with PRECICE is reliable, but larger trials with longer follow-up will reveal limitations. Implantable nails prevent problems associated with external fixation, such as muscle tethering and pin-site infections.

Growth Disturbance of the Distal Tibia in Patients With Idiopathic Clubfeet: Ankle Valgus and Anteflexion of the Distal Tibia.

BACKGROUND: The aim of this study was to evaluate the incidence of deformities of the distal tibia in patients with idiopathic clubfeet who had undergone surgical intervention with a circumferential release through a Cincinnati incision in early infancy. METHODS: A retrospective follow-up evaluation of children with idiopathic clubfoot was conducted. We reviewed children who had undergone surgical treatment by a circumferential release in our department after unsuccessful casting, and who were at least 10 years of age. Main focus was the measurement of anteroposterior and lateral view radiographs for distal tibia deformities. Of 65 patients (93 feet) who had surgery for idiopathic clubfoot from 1998 to 2002, radiographic data of 35 patients (52 feet) were analyzed. RESULTS: An anteflexion deformity was present in 25 of 52 feet (48.1%) and a valgus deformity in 29 of 52 feet (55.8%). A flat-top talus was evident to some degree in all cases. An abnormal lateral talocalcaneal angle was evident in 42.3%. CONCLUSIONS: These results show the importance of conducting follow-up evaluations on patients with idiopathic clubfoot for secondary deformities of the distal tibia. This is the first study, to our knowledge, highlighting the high incidence of distal tibial deformities after surgery for idiopathic clubfoot. It is unclear at this time whether this is also true for clubfeet after conservative treatment. However, patients with clubfeet should have radiographs of the ankle joint between the age of 10 and 12 years to be able to treat possible deformities through guided growth. LEVEL OF EVIDENCE: Level III.

Bilateral double level tibial lengthening in dwarfism.

PURPOSE: Outcome assessment after double level tibial lengthening in patients with dwarfism. METHODS: Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. RESULTS: Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm. CONCLUSION: Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying.

Distraction osteogenesis for complex foot deformities: Gigli saw midfoot osteotomy with external fixation.

Open midfoot wedge osteotomy correction can cause neurovascular compromise, requires extensive exposure, sacrifices normal joints, and shortens the foot. We used a minimally invasive technique to treat complex foot deformities by combining percutaneous Gigli saw midfoot osteotomy, circular external fixation, and acute, gradual, or gradual with acute manipulation correction. The medical records of 23 patients (26 feet) with complex foot deformities (congenital, 18 feet; neuromuscular, 4 feet; post-traumatic, 3 feet; malunion, 1 foot) who had undergone treatment within an 18-year period (1990 through 2007) were retrospectively reviewed. We also performed the procedure on 10 cadaveric limbs to determine whether anatomic structures were at risk. Correction was achieved in all feet. The mean duration of external fixation treatment was 4.2 (range 3 to 7) months. The mean follow-up duration was 4.7 (range 2 to 18) years. A significant difference was observed in the pre- and postoperative, lateral view, talar-first metatarsal angle (p = .001). Minor complications (4 feet) consisted of bony exostoses. Major complications included recurrent deformity in 3 feet and sural nerve entrapment in 1 foot. Two patients had mild and one moderate foot pain. Three patients had impaired gait function; the remaining patients had functional gait. The mean interval until wearing regular shoes after external fixation removal was 2.3 (range 1 to 4) months. All but 1 of the patients were satisfied with the final results. We observed no cadaveric neurovascular injury. Our results have shown that percutaneous Gigli saw midfoot osteotomy can be performed without neurovascular injury and is capable of successfully correcting complex foot deformities.

Preliminary experience with motorized distraction for tibial lengthening.

Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.

Exothermic properties of plaster-synthetic composite casts.

PURPOSE: Plaster casts can cause burns. Synthetic casts do not. Composite plaster-synthetic casts have not been thoroughly evaluated. This study analyzed the temperature from plaster casts compared with composite casts in a variety of in vitro conditions that would simulate clinical practice. METHODS: A Pyrex cylinder filled with constant body temperature circulating water simulated a human extremity. Circumferential casts, of either plaster or composite construction (plaster inner layer with outer synthetic layer), were applied to the model. Peak temperatures generated by the exothermic reactions were studied relative to the following variables: dip water temperature (24 °C versus 40 °C), cast thickness (16, 30, and 34 ply), and delayed (5-min) versus immediate application of the synthetic outer layers. Peak temperatures from the all-plaster casts were compared with the composite casts of the same thickness. Finally, the relative cast strength was determined. RESULTS: Potentially dangerous high temperatures were measured only when 40 °C dip water was used or when thick (30- or 34-ply) casts were made. Cast strength increased with increasing cast thickness. However, the presence of synthetics in the composite casts layers did not increase cast strength in every case. CONCLUSION: When applying composite casts, the outer synthetic layers should be applied several minutes after the plaster to minimize temperature rise. Composite casts do not routinely generate peak temperatures higher than plaster casts of similar thickness. Because the skin of children and the elderly is more temperature-sensitive than average adult skin, extra care should be taken to limit the exothermic reaction when casting children and the elderly: clean, room temperature dip water, minimal required cast thickness, avoidance of insulating pillows/blankets while the cast is drying.

Resistant metatarsus adductus: prospective randomized trial of casting versus orthosis.

BACKGROUND: Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is usually a mild deformity that responds well to simple observation or minimal treatment with a home program of stretching. Resistant cases may need a more aggressive approach such as serial casting or special bracing to avoid the need for surgical intervention. We compared clinical outcomes using serial casting with orthoses for resistant metatarsus adductus. METHODS: We prospectively treated 27 infants (43 feet) between the ages 3 and 9 months who failed home stretching treatment. Patients were randomized to either serial plaster casting or Bebax orthoses. Footprints and simulated weight-bearing anteroposterior and lateral view radiographs were made at entry and follow-up. RESULTS: There was no statistical difference between casting and Bebax for the following parameters: age at study entry, length of treatment, number of clinic visits, follow-up, and follow-up maintenance treatments. Both groups showed improvement in footprint and radiographic measurements post-treatment, without worsening of heel valgus. The Bebax group had greater improvement in the footprint heel bisector measurement than the casting group. The Bebax treatment requires more active parental cooperation. A simulated cost analysis of materials and office visit charges, however, revealed that Bebax treatment was significantly less expensive, about half the cost of casting. CONCLUSION: Because of the cost savings and virtually identical clinical results, we recommend the Bebax orthosis for resistant metatarsus in pre-walking infants with parents who are compliant. Other considerations include specific insurance plans, which may pay for casts but not orthoses.

Compartment syndrome of thigh and lower leg with disruption of the popliteal vascular bundle after being run over by a 25-ton truck.

Compartment syndrome of the thigh is a rare condition, potentially resulting in devastating functional outcome. Increasing intracompartmental pressure which suppresses microcirculation and capillary perfusion may lead to cellular anoxia and muscle ischemia. The muscle compartments in the thigh have a more compliant fascia and blend anatomically into the open compartments of the pelvis, thus compensating higher volumes than the compartments in the lower leg. We present a previously unreported case in which the limb of a 36-year-old man was run over by a 25-ton truck. He presented with a sensomotor deficit in his left lower leg with full paralysis of the shank muscles and absence of all foot pulses. CT scan showed a huge haematoma in the thigh with active bleeding out of the popliteal artery into the haematoma which has already expanded into the muscle compartments of the lower leg. The limb had a disastrous compartment syndrome of the thigh and lower leg with disruption of the popliteal neurovascular bundle; however, no bones in the limb were fractured. A complete fasciotomy of all the lower limb muscle compartments was immediately performed. The artery was reconstructed with interposition of the smaller saphenous vein, which was already interrupted through the initial trauma.

Lower limb alignment in the frontal plane: analysis from long standing radiographs and computer tomography scout views: an experimental study.

OBJECTIVES: A profound knowledge of physiologic lower limb alignment is essential to understand deformities and to plan surgical correction. The gold standard in radiographic assessment is the long standing radiograph with a forward directed patella. The advantage of computed tomography (CT) is that its cutting-edge image technique can visualize the femur condyles. Study purpose was to determine if the CT-scout view has the potential to replace the standing radiograph. MATERIALS AND METHODS: We compared the geometric data obtained from long standing radiograph and CT-scout views both with patella forward position. Furthermore, we developed a method of positioning the lower extremity stable on the CT table, where the femoral condyles became the new orientation criterion. Finally, we evaluated differences in the data ascertainment between the long standing radiograph with patella facing forward and the CT-scout view with the posterior edge of femoral condyles orientated parallel to the radiographic cassette. RESULTS: The geometric data of long standing radiograph and CT-scout views are comparable if the leg is in the same rotational position. We developed a CT positioning jig to adjust the femur condyles parallel to the radiographic cassette. In 80 % of the cases, the deviation was 5° or less. These scout views showed statistically significant differences when compared with data from standing radiograph with a forward centered patella. CONCLUSION: No evidence was found clearly excluding the possibility of an exclusive use of the CT-scout view for the analysis of the leg geometry. However, advantages of the long standing radiograph became obvious.

A technical note on improved instrumentation for Blount staple insertion.

PURPOSE: Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight-Plate Guided Growth System. Since its introduction, the eight-Plate has largely supplanted the traditional Blount staple. The eight-Plate offers better purchase in the bone and a more precise insertion technique. However, the Blount staple is less expensive than the various guided growth plates. Further, some surgeons feel that the Blount staple may work faster, making it more appropriate for children who are approaching skeletal maturity. Unfortunately, the original instrumentation and technique for inserting the Blount staple is over 50 years old and has not been updated. METHODS: The purpose of this study was to develop new instrumentation to make Blount staple insertion as accurate and minimally invasive as eight-Plate insertion. We developed wire/drill guides to accommodate all three sizes of the Blount staple. Two wires are inserted through the wire guide under image intensifier control. After confirming the accurate position of the guidewires, a 3.2-mm cannulated step drill is used to drill over the wires to a depth of 5 mm. This creates two pilot holes for the two tines of the Blount staple. The final insertion is guided under an anteroposterior image intensifier view. We also developed a small staple holder that permits insertion through a small incision. RESULTS: We developed a working prototype of the new instrumentation and used it in three clinical cases. CONCLUSIONS: With the new staple inserter and instrumentation, Blount staples can now be inserted through a smaller incision with similar accuracy as eight-Plate insertion.

Trigonometric analysis of the mechanical axis deviation induced by telescopic intramedullary femoral lengthening nails.

Femoral lengthening with intramedullary nails can create alterations in the mechanical axis of the limb. This is based on the relationship of the anatomic femur axis to the mechanical femur axis, which is typically 5-9 degrees valgus. We developed trigonometric formulas to calculate the predicted change, using the lengths of the tibia, femur, and whole limb; the amount of lengthening; and the angle between the anatomic and the mechanical axis of the femur. We recognized three patterns depending on whether the overall limb mechanical axis is lateral (valgus), medial (varus), or straight through the center of the knee. The varus and valgus patterns lead to similar formulas. When the mechanical axis goes directly through the center of the knee joint, the formula simplifies. These formulas could be incorporated into digital radiographic programs to predict the change in mechanical axis deviation that will develop from lengthening along the anatomic femur axis with an intramedullary lengthening nail.

Hemiepiphyseal arrest in a porcine model.

BACKGROUND: Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients can avoid the need for osteotomies. Recently, newer implants have been introduced as alternatives to the Blount staple, which was commonly used for the past 60 years. The purpose of this project was to develop a porcine model that can be used to compare various methods of temporary hemiepiphyseal arrest. In this pilot study, we compared the Blount staple and the eight-Plate. We hypothesized that the Blount staple, a fixed angle device, tethers growth immediately, whereas the eight-Plate, having mobile arms, has a certain lead time to take the slack out of the system until it can begin to tether growth. METHODS: A porcine model was selected due to its widespread availability and because its size approximates human pediatric dimensions. Thirty-day-old, 15-kg piglets underwent surgery to insert an eight-Plate in each right proximal medial tibia and a Blount staple in each left proximal medial tibia. The insertion technique was identical to the surgical procedure performed in humans, including the use of image intensification. Anteroposterior and lateral view tibial radiographs were obtained monthly until sacrifice at 3 months after insertion to measure the medial proximal tibial angle. RESULTS: At 1 month follow-up, a large varus deformity up to 30 degrees had already occurred with both devices. In some piglets, the implants were even dragged, by growth, through the epiphysis during the first two months. With further follow-up, the Blount staples frequently migrated to the proximal metaphysis. We observed rebound in four tibiae after implant migration, with partial restoration of the normal limb alignment. CONCLUSIONS: The porcine model for temporary hemiepiphysiodesis seems to have promise for future studies. However, the unusually rapid rate of growth causes us to recommend more frequent observation periods, such as weekly instead of monthly radiographic observation.

Temporary hemiepiphysiodesis with the eight-Plate for angular deformities: mid-term results.

BACKGROUND: Angular deformities can be treated with corrective osteotomies and application of internal or external fixation. In children, this major intervention can be avoided with temporary hemiepiphysiodesis (i.e., guided growth). Recently, a new device called the eight-Plate Guided Growth System, consisting of a two-hole plate and two screws, was presented as an alternative to the widely used Blount staple to perform temporary hemiepiphysiodesis in children. METHODS: Forty-three patients (54 physes, 51 limbs) underwent treatment between August 2004 and December 2005 with average follow-up after plate insertion of 2 years 2 months (range, 1 year 6 months to 2 years 6 months). Rate of correction and reversibility of this intervention were calculated. RESULTS: Average age at eight-Plate implantation was 9 years 7 months (age range, 4 years 0 months to 14 years 3 months). eight-Plates were inserted for an average 14.2 months (range, 5.0-27.4 months). No growth disturbance was observed. Mechanical lateral distal femoral angle changed an average 10.00 degrees (range, 1-18 degrees) or 0.65 degrees/month (range, 0.05-1.22 degrees/month). Medial proximal tibial angle changed an average 7.78 degrees (range, 0-14 degrees) or 0.58 degrees/month (range, 0.13-1.67 degrees/month). In the two distal tibial cases, lateral distal tibial angle improved 6 degrees and 10 degrees (average change, 0.44 degrees/month). Mechanical axis deviation improved an average 25.4 mm (range, 0-74 mm) or 1.73 mm/month (range, 0-6.4 mm/month). Ten patients (13 limbs) had more than 10 months of radiographic follow-up after plate removal; ten limbs showed average rebound of 15.7 mm or 1.0 mm/month, indicating the reversibility of this procedure. Four cases failed to achieve correction. CONCLUSIONS: The eight-Plate effectively treats angular deformities in growing children and is less likely to extrude spontaneously than the Blount staple. We have not observed growth disturbance or other complications related to this device.

Mechanical failures of eight-plateguided growth system for temporary hemiepiphysiodesis.

BACKGROUND: For decades, the Blount staple has been used to perform temporary hemiepiphysiodesis for angular deformity correction in children with open growth plates. Recently, the eight-PlateGuided Growth System (Orthofix, McKinney, TX) has gained popularity for use in this procedure. The eight-Plate is said to be superior to the Blount staple, as it is less likely to break or migrate out of the bone. However, some centers have observed mechanical failures of the eight-Plate cannulated screws. METHODS: The purpose of our study was to conduct a multicenter survey to determine which factors increase the risk of mechanical failure with this device. We distributed a questionnaire in 2007 to 841 members of the Pediatric Orthopaedic Society of North America that asked about their experience with the eight-Plate and whether they had observed any mechanical failures. Follow-up surveys were distributed to determine the background of the failed cases. RESULTS: Of the 445 (53%) surgeons who responded, 314 (71%) reported that they use the eight-Plate in their practice. Forty-eight (15%) of the 314 surgeons who use the eight-Plate observed a total of 65 cases of mechanical failure. In every case, the screws failed, not the plate. The average body mass index of these patients was 37.8 kg/m (range, 19.2 to 70.2 kg/m). CONCLUSIONS: Overweight and obese patients with Blount disease were among those most likely to experience eight-Plate screw failure. Fractures occurred almost always in the metaphyseal screw-not where the head meets the shank but where the shank enters the lateral cortex, presumably because of 3-point bending. No broken plates were reported. In high-risk cases, we now consider using 2 parallel eight-Plates or using solid (not cannulated) screws for plate fixation. LEVEL OF EVIDENCE: Level IV.

Compartment syndrome of the thigh. A case report with delayed onset after stable pelvic ring fracture and chronic anticoagulation therapy.

Compartment syndrome of the thigh is a rare occurrence potentially leading to devastating functional restrictions. There is a wide spectrum of reported conditions leading to increased tissue pressure in the thigh possibly resulting in a compartment syndrome, ranging from deep venous thrombosis to blunt injuries and femoral fractures. We report a case of a delayed development of a compartment syndrome of the thigh secondary to an undisplaced anterior pelvic ring fracture and chronic anticoagulation therapy in a 94-year-old woman. Regarding anticoagulation therapy there are numerous reports about the spectrum of bleeding complications during therapy, however this severe complication has to our knowledge not been reported previously. Treatment consisted in immediate fasciotomy and subsequently secondary wound closure.

Medial migration of lag screw with intrapelvic dislocation in gamma nailing--a unique problem? A report of 2 cases.

Within the last decade, intramedullary nailing systems have gained popularity in the treatment of unstable fractures of the trochanteric region with good clinical results. However, these implants are not free of complications. Commonly reported treatment failures include implant cutout through the femoral neck, stress-derived femur fractures at the distal end of the nail, and secondary rotational displacement and varus deformity of the femoral neck and head. Only few reports exist on primary medial migration of the lag screw after treatment with intramedullary implants. We report on a rarely described complication in 2 patients who underwent osteosynthesis with a Gamma 3 nail (Stryker, Mahwah, NJ). Both patients presented with implant failures due to primary medial migration of the lag screw. Complete separation of the implant occurred, and the lag screw penetrated through the acetabulum into the pelvis. The patient's histories and course of treatment are reported. The literature on this topic is discussed.

Tibial lengthening: extraarticular calcaneotibial screw to prevent ankle equinus.

UNLABELLED: Between 2003 and 2006, we used an extraarticular, cannulated, fully threaded posterior calcaneotibial screw to prevent equinus contracture in 10 patients (four male and six female patients, 14 limbs) undergoing tibial lengthening with the intramedullary skeletal kinetic distractor. Diagnoses were fibular hemimelia (two), mesomelic dwarfism (two), posteromedial bow (one), hemihypertrophy (one), poliomyelitis (one), achondroplasia (one), posttraumatic limb-length discrepancy (one), and hypochondroplasia (one). Average age was 24.5 years (range, 15-54 years). The screw (length, typically 125 mm; diameter, 7 mm) was inserted with the ankle in 10 degrees dorsiflexion. Gastrocnemius soleus recession was performed in two patients to achieve 10 degrees dorsiflexion. Average lengthening was 4.9 cm (range, 3-7 cm). Screws were removed after a mean 3.3 months (range, 2-6 months). Preoperative ankle range of motion was regained within 6 months of screw removal. No neurovascular complications were encountered, and no patients experienced equinus contracture. We also conducted a cadaveric study in which one surgeon inserted screws in eight cadaveric legs under image intensifier control. The flexor hallucis longus muscle belly was the closest anatomic structure noted during dissection. The screw should be inserted obliquely from upper lateral edge of the calcaneus and aimed lateral in the tibia to avoid the flexor hallucis longus muscle. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.