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Some children have blue sclera, obvious dentinogenesis imperfecta, triangular facles, and ligamentous laxity, but this varies greatly, even within the same family, and many affected children have none of these findings. A single distal lateral-to-proximal medial Kirschner wire is placed percutaneously (not through the incision) to hold the osteotomy apposed. If exposure still cannot be accomplished, a formal lateral retinacular release may be required. The prosthesis is then inserted into the doughy mass of cement with the centralizer attached to the tip. Larger fragments, even those without soft tissue attachments, are needed to restore the structure of the lateral process in any closed fracture of the lateral process of the talus. Restored physeal growth was, on average, 86% of the contralateral physeal growth rate. The mechanical axis is drawn from the center of the femoral head to the center of the knee joint, whereas the anatomic axis is the central axis of the femoral shaft. Palpate along the joint line, medial and lateral collateral ligaments, iliotibial band, and pes anserine to identify any tenderness suggestive of focal injury. These results include ankle and subtalar joint stiffness, posttraumatic arthrosis, and osteonecrosis of the talus. A soft tissue interference screw is placed in the femoral bone tunnel to lock the hamstring graft into the tunnel after the looped graft is pulled into the tunnel when the guide pin is advanced across the femur. Immediately inferior to the pedicle of L5 the nerve transgresses anterior to the sacral ala, separated by a distance of 1. The Achilles tendon often is contracted and may make exposure of the calcaneus difficult. The anterior periosteum is usually thinner than the posterior, often leading to hinging of the fragments posteriorly and possible entrapment of the periosteum anteriorly. Osteochondral lesions larger than 1 cm in diameter should be repaired if any bone is attached to the chondral fragment. Measuring the Fassier-Duval Nail the distance from the greater trochanter to the distal femoral physis can be used to estimate the length of the female nail. Pelvic osteotomies for the treatment of hip dysplasia in children and young adults. Do not ream the entire femoral head all the way to the distal rim of the femoral head. With the three sutures held tight, the knee is placed through a range of motion, from full extension to 90 degrees of flexion, to check that enough imbrication has been performed. This enables exposure of the direct (pictured) and indirect heads of the rectus femoris tendon. The risk of aseptic loosening can be decreased by use of well-designed implants and modern cement technique. When the child is under anesthesia, the spastic component is effectively removed, allowing the physician to perform a clinical examination to determine the presence or absence of myostatic or fixed muscle shortening. Ultrasounds of dislocated right hip with alpha angle of 56 degrees (A) and normal left hip with alpha angle 66 degrees (B). Appropriate cement viscosity has been reached when the cement no longer sticks to the surgical gloves. Pedicles Dimensions In scoliotic spines, average lumbar pedicle length is 20 to 22 mm. Pain relief was achieved in 88% of patients at 1 year and 73% of patients at the latest follow-up. The remodeling stage extends from the end of reossification until skeletal maturity. Small lesions (ie, those that involve less than one third to half of the bone width) in weight-bearing bones that have low risk for fracture can also be observed.

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The pathogenesis and natural history of some of the more common disorders associated with neuromuscular spinal deformity and spinal deformity within the disease follow. It originates from two heads: Sternal head: superior and anterior surface of manubrium sterni. Therefore, the most medial location of the osteotomy is different for the posterior and anterior aspects of the tibia. The hereditary multiple epiphyseal disturbance and its consequences for the aetiogenesis of local malacias, particularly the osteochondrosis dissecans. Avascular Necrosis Avascular necrosis has been documented in 9% to 43% of hips after medial open reduction. The posterolateral approach is desirable for its excellent, extensile exposure and avoidance of trauma to the abductor mechanism. The facet joint is removed to obtain a flat surface before placing the pedicle screw. When the ulna is lengthened, the cordlike portion of the interosseous membrane tends to pull the radius distally. Because the skin is mobile in the child, the incision can be easily moved to complete the exposure of the iliac crest and the anterior aspect of the hip without having it rest directly on the iliac crest. The stability of the bone is maintained postoperatively and the patient may continue to ambulate. If the retractors are left in, they have the effect of tightening the soft tissues, artificially diminishing the gap. Ideally the rod spans enough of the tibia to provide long-term mechanical support and protection of the pseudarthrosis. Instrumentation is introduced after posterior exposure of the thoracic or lumbar spine (see Chap. When inserting the true implants, do not completely seat the proximal sleeve prior to placing the stem when using a long, extra-long, or extra-extra-long sleeve. If the femoral component is not stable within the femoral canal and if there is obvious rotation or risk of significant subsidence, a third batch of antibioticloaded cement is mixed. An anterior bridge of soft tissue remains along the greater trochanter between the incision in the vastus lateralis and the incision in the gluteus medius and superior capsule. Correction of Valgus Deformity Correction of Flexion Contracture Use a curved osteotome to release osteophytes in the back of the femur and then extract them with a rongeur. One-stage correction of the spastic dislocated hip: use of pericapsular acetabuloplasty to improve coverage. The iliotibial band is detached proximally under the skin using a curved meniscotome or an open tendon stripper. An Ortolani-positive hip is dislocated or subluxated and the examiner perceives that the hip partially reduces with abduction. It is important to rule out concomitant glenoid fracture or dislocation before surgery. The shoulder draping should permit the anesthesiologist to hold the shoulder, which can maximize tension during this test. This then transitions to a trend toward a more lateral and caudal pedicle starting point as one proceeds proximally from the apex. As in all fractures in young children, child abuse must be suspected if the history is unclear or multiple fractures are present. Use of the Ilizarov method to correct lower limb deformities in children and adolescents. A bump is placed under the lumbosacral area, and the entire lower extremity is draped free. Contributing factors to the hip joint pathology may include musculotendinous contractures, ligamentous laxity, and coexistent acetabular dysplasia. Injury to the cutaneous nerves is common, and patients should be warned of this risk.

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Direct questions should be asked to determine whether pain control was adequate in the postoperative period. The curved superior retractor is placed deep to the gluteus minimus just over the superior femoral neck and capsule. A positive examination with radicular pain denotes either an L5 or S1 nerve root compression. Unrestricted range of motion without external immobilization may be allowed (eg, most adults). The plantaris arises just above the lateral head of the gastrocnemius and inserts into the calcaneus. Elbow dislocations that have reduced before presentation are not uncommon, so it is helpful to ask the patient and family whether a marked deformity was noted at the time of injury. The goal of impaction bone-grafting is to achieve immediate implant stability with the use of compacted, morselized bone graft. The amount of acetabular redirection possible is approximately equivalent, but medialization of the joint center is achieved easily with the Bernese osteotomy. The knee immobilizer brace should not be applied with a force that impedes circulation. It is better to overimmobilize in questionable cases to avoid malalignment and regain motion later with aggressive physiotherapy. Note the relative dorsiflexed position of the foot as compensation for the anterior angulation of the distal tibia. Femoroacetabular impingement is caused by overcoverage of the acetabulum (ie, retroversion). The extent of load depends on the stability of fragments and the amount of regenerate. No study has shown a Tegner Activity Score greater than 4 with total knee arthroplasty or unicompartmental knee arthroplasty. Entry into the distal radius entry site should be directly visualized, and the feel of the nail within the intramedullary canal offers distinct tactile feedback called "scrape. Rett Syndrome this is an X-linked disorder that affects females almost exclusively. A Schanz screw is driven into the tuberosity to facilitate manipulation of the fragments. If intact, the deep deltoid ligament, which is short and nonelastic, allows for little motion, minimizing the yield of successful closed reduction. According to the degree of compression and the affected site of the spinal cord, signs and symptoms can vary. Acetabular osteotome systems facilitate cup removal by using the center of the acetabular polyethylene as a reference for osteotome insertion. Physical or occupational therapy is rarely needed in children but may be recommended for those who fail to show improved range of motion. Place a sandbag beneath the ipsilateral shoulder/scapula and rolled sheets (as bump) beneath the humerus and radius ulna to create a space for the frame. To achieve a proper soft tissue balance, initially remove the offending osteophytes until the anatomic margins of the bone are determined. Bovie cautery is used to subperiosteally expose the posterior elements out to the tips of the transverse processes. After the patient is positioned, prepared, and properly draped and the anatomic landmarks are identified, a 3- to 5cm incision is carried over the capitellum. The anterior and posterior margins of the fascia lata are identified and dissected proximally. There may be a slight increased risk of subsequent lateral condyle fractures in children with cubitus varus. Alternatively, bone cement or a synthetic bone graft substitute filler can be used to pack small, contained defects between the revision implant and host bone. Radiographic signs include full-thickness cartilage loss with eburnated bone-on-bone contact in the medial compartment; full-thickness cartilage preservation in the lateral compartment; intact articular surface at the back of the tibial plateau; and manually correctable varus deformity.

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Depending on the optimal site for pin insertion, the half-pin fixation bolt or Rancho cube is attached to the ring. Placement of pedicle screws at L5 can be difficult because the surgeon must direct the screws in an awkward trajectory. Once the rod is inserted and locked proximally with a guide arm, additional compression can be achieved at the knee fusion site by holding the foot and driving the rod in more with three or four more mallet slaps to the insertion handle. The gray area represents the optional trochanteric osteotomy, which is recommended only when the correction angle exceeds 25 degrees. The surgeon should be wary of operative treatment for patients with pain without instability. The drill guide is placed over the pin and slid onto the surface of the femoral head to verify the position of the guide pin. Wide exposure and identification of the major landmarks of the acetabulum are necessary. Three screws are placed proximal and three screws distal to the fracture (rarely there is room for only two screws). There is variable signal intensity in both T1- and T2weighted images due to the nature of the cyst contents (fresh blood, mixed with degraded blood products). Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Impingement of the femoral head upon the acetabular rim takes place during motion of the hip, particularly with flexion and internal rotation. Excessively stiff scoliosis or accompanying sagittal plane deformity (hyperkyphosis or hyperlordosis) Rod insertion Using the wires to pull the rod down to the lamina may cause the wires to cut through the lamina. Greater than 10 degrees of fixed flexion deformity should be corrected during preparatory procedures. Complications Postoperative care Strict foot elevation until suture removal is recommended to assist in wound healing. Joint stabilization is the key to success of rebalancing the thumb-deforming forces. The annulus fibrosis is the circumferential fibrous tissue that surrounds the nucleus pulposus, which is in the center of the disc. The long-stem component is introduced slowly but early during the cement cure state, before the viscosity of the cement has increased. For a patient who has sustained a pathologic fracture secondary to metastatic carcinoma, the average survival time is 19 months. Periacetabular osteotomy may positively impact the natural history of joint degeneration in acetabular dysplasia,24 but the long-term effect of osteotomy on hip function and progression of athrosis is unknown. After placing two parallel K-wires proximal and distal of the planned osteotomy for later rotational control, the osteotomy is performed under protection of the surrounding soft tissue. Somatosensory evoked potentials, transcortical motorevoked potentials, and electromyography are the preferred neurologic monitoring modalities. The distal femur then is prepared using the instrumentation particular to the system being used. If the patient has an open physis, an oblique interfragmentary screw is passed across the osteotomy site beginning just proximal to the physis. When using a dual-rod system, the posterior screws are initially placed angled in the midaxial plane, while the anterior screws are directed slightly posteriorly. Sternocleidomastoid pseudotumor and congenital muscular torticollis in infants: a prospective study of 510 cases. A trochanteric ostetomy, either conventional or extended, may improve exposure of the acetabulum and pelvis. Specific anatomy and growth plate closure patterns create certain fractures in adolescence. The presence of this debris increases over time, leading to a macrophage response that results in periprosthetic bone loss. The tension band of the vastus lateralis muscle is re-established with 0 absorbable suture. This is the deep fascia, which can then be further exposed distally by using a sponge on the fascia. The joint capsule is incised along the line formed by the superior margin of the piriformis muscle.

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Open reduction and internal fixation approaches are the same as described for adult injuries elsewhere in this text. After exiting the far skin, the wire is inserted further by tapping with a mallet. Valgus instability indicates a medial elbow injury in addition to an unstable radial neck fracture. Ankle valgus may be mistaken for (or coexist with) planovalgus deformity of the foot. About 50% of all patients with Perthes disease have severe degenerative arthritis by the sixth and seventh decades of life. Implant Placement Perform trial reduction after placing the trial sleeve and femoral stem to assess version, range of motion, and laxity. In nontraumatic conditions, ligamentous laxity (particularly in the transverse ligament) or abnormalities of the odontoid cause instability. The incisions are closed with subcuticular suture, and a posterior splint is applied to allow tissue healing. The paraspinal musculature is partially innervated in a flexion position lateral to the bony ridges owing to lack of posterior migration from an embryologic origin. Large nonincorporated fragments of cartilage also were found, particularly in cases in which femoral head bone chips were produced by a bone mill. Thoracoscopic techniques for the treatment of scoliosis: early results in procedure development. Radiographs may confirm increased displacement of the medial epicondylar fragment. When adequate bony support is achieved, the joint surface restored, and flexion and extension gaps balanced then the component to be implanted is constructed to match the trial and appropriately cemented into place. It can be done without violation of the abductor mechanism, facilitating a relatively rapid recovery. Quantitative sensory testing is the best method to identify early nerve entrapment. Despite initial fluoroscopic views indicating an adequate reduction, the radiographs indicate a poor reduction. Computed tomography shows bone well and is most helpful to evaluate hip incongruity during the late stages of remodeling and during young adulthood. The surgeon must become familiar with the morphology of the bone and its many contours to facilitate reconstruction. Gore-Tex liners are used at some institutions to prevent diaper rash and superficial infections. They will not effect any growth modulation or improvement in skeletal alignment, however. The interface of the femoral, tibial, and patellar components with bone must be visualized. The posterior facet is reduced under direct vision, and the reduction is confirmed with fluoroscopy. The tendon of the gastrocnemius is identified proximal to the conjoined tendon and the interval in between the gastrocnemius tendon and the underlying soleus fascia may need to be developed. The femur is reamed to the appropriate depth (femoral tunnel length EndoButton length 6 to 7 mm to flip the EndoButton). Malunion of fractures can occur with operative or nonoperative treatment or can be a secondary consequence of premature physeal closure. Positioning the patient is adequately padded and placed in the lateral decubitus position. There is a small hole in the distal male nail to allow interlocking with a small wire, which is then bent over into the epiphysis. Improvements in prosthesis design and biomaterials have increased the usefulness and versatility of metal augments in addressing larger bone defects.

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As a result of the slight varus in the tibia, the distal femur actually is in 9 degrees of valgus, resulting in a combined femorotibial alignment of 6 degrees when the knee is in extension. Apply modest insertion pressure to the poly cup with partially polymerized doughy cement. This bridge consists of the anterior fibers of the gluteus medius, minimus, and capsule. Adequate release of the rectus femoris muscle cannot be achieved through a small incision. Intraoperative navigation can demonstrate real-time positioning of instrumentation by imaging, thereby improving the accuracy of component positioning in hip resurfacing arthroplasty. Numerous techniques have been described for reattaching the abductor mechanism to the implant. Sometimes a lateralizing reamer is used to ensure direct access to the femoral canal and minimize the possibility of varus implantation. Two-year postoperative radiographs following an open anterior fusion and instrumentation from T11 to L2 with dual rod-dual screw system and anterior cages placed at the T12-L1 and L1-L2 levels with excellent coronal plane correction. The remaining procedures for femoral component are done in the same manner as those for conventional resurfacing procedures described earlier. Although somewhat bulky, the "double stack" configuration of the frame allows for easy dynamization. In complex triplane fractures, screws often need to be placed both at the level of the epiphysis and the metaphysis, as dictated by the specific fracture pattern. A neurologic evaluation assesses distal radial, medial, and ulnar nerve motor and sensory function. Many important symptoms may not be readily volunteered by the patient, but must be sought by the orthopedist. With the bearing in place, the knee is manipulated through a full range of motion to demonstrate stability of the joint, security of the bearing, and absence of impingement. The appropriate block augment cutting guide is then selected and positioned over the previously placed cutting guide pins, and medial or lateral step cuts are performed. The first step is ensuring that the proximal and distal ends will be well approximated to the bone. Equinovalgus deformity with missing lateral rays indicates concurrent fibular hemimelia. A vertical cut is made at the medial edge of the facet, near the base of the spinous process. A full-length radiograph from the hip to the ankle is helpful in determining the mechanical axis of the limb and noting unusual shaft bowing or deformities in some cases. The height and diameter of the pedicles increases from the thoracic to the lumbar spine. Lengthening Via External Fixators Femoral lengthening with an external fixator can be performed with various devices. If tendon transfer has been done, immobilization should be extended to 6 weeks, followed by additional splinting for 6 weeks. If the proximal femur cannot be placed in this position, there is an abduction contracture of the hip joint. Ankle range of motion is now increased to 10 to 15 degrees of dorsiflexion with the knee extended. The surgeon dissects deep to the medial retinaculum, posterior to the medial epicondyle and the medial intermuscular septum. This is essential to allow for proper and precise sizing of the femoral implant and to prevent notching. If surgery is being considered, skin over the affected hip should be assessed for mobility and for the presence and location of scars from any prior surgical procedures, which may influence surgical approach. For a metatarsal base fracture or fracture-dislocation pattern precluding transarticular fixation, bridge plate fixation may be required.

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Greenstick fracture patterns retain a degree of inherent stability; intentional completion of these fractures is not recommended. A step cut is not necessary because of the rotational stability of the bowed, slotted stem. At birth, the normal amount of hip abduction range of motion is 60 to 90 degrees, significantly greater than the expected range of motion of adults. Anatomic trajectory has a longer bone channel and allows a longer screw to be placed, but mandates the use of a multiaxial screw to connect it to the rod. At the intertrochanteric level, two wires are inserted perpendicular and parallel to the side plate. Spinal Cord Injury Spinal cord injury in the skeletally immature child is associated with a nearly 100% incidence of scoliosis. At that point the pin is removed and the patient is changed to a removable splint. Fractures of the calcaneus: open reduction and internal fixation from the medial side: a 21-year prospective study. Range of motion is assessed to rule out secondary femoroacetabular impingement and instability. Such closure may lessen the chance of lateral spur formation, add stability, and speed healing. All inside techniques are less successful when used for the lateral meniscus, especially with larger tears. The arthroscope can be used to assess the portions of the capitellum not clearly visualized through the arthrotomy site, much like a dental mirror. Preoperative Planning If manipulative reduction is contemplated, the surgeon should request muscle relaxation from the anesthesia provider after induction. Flattening of the skull and facial bones can develop on the affected or normal side depending on the sleeping position of the child. This technique is best for infants, small children, or patients with an abnormally shaped skull. A long-arm cast or splint is applied with the elbow in 90 degrees of flexion and the forearm in slight prona- tion. If healing is inadequate (which is more likely in higher-energy injuries in older children), the cast (and the pins if used) is continued for 2 more weeks, after which patient is re-evaluated for healing. To reduce the potential risk of femoral neck fracture, we perform total hip resurfacing arthroplasty using computerassisted navigation. Predictable stiffness with range of motion and posttraumatic arthritic changes is experienced with severe fractures of the talus. Measurement of the Cobb angle on radiographs of patients who have scoliosis: evaluation of intrinsic error. Bone loss with revision total knee arthroplasty: defect classification and alternative for reconstruction. After the osteochondroplasty is completed and inspected by direct physical examination and fluoroscopy, the osteochondroplasty bony bed is treated with bone wax. A fibular strut graft is fashioned and inserted into the sacrum to the body of L5. Permanent ligation can be performed after 20 minutes of normal spinal cord monitoring. Patient education is important to maximize understanding of wound risks and compliance with elevation and other postoperative treatments. The durability of cement fixation is highly dependent on meticulous surgical technique. As the tibia grows away from the ends of the rod, bowing may increase through this unprotected segment. Coumadin can be administered for several weeks for medical prevention of deep vein thrombosis. Central physeal bar resection is typically performed by approaching the physis through the metaphysis adjacent to the physeal bar.

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Attention is turned to the medial wall, where the superomedial fragment is identified. The lateral margins of these vertebral bodies are removed, including the transverse process and posterolateral bone. The pin is advanced into the head, stopping several millimeters below the subchondral bone. A tensioned soft tissue graft in a bone tunnel across the physis can also induce a growth disturbance. The risk of redislocation is three times higher in patients treated with immediate mobilization versus immobilization with cast or brace. Patients with some disorders, such as Charcot-Marie-Tooth disease, may appear to have equinus, but the true deformity is plantarflexion of the midfoot. Physical therapy should be instituted to regain motion, strength, and proprioception before resuming activities. General guidelines are available to define acceptable healing alignment (Table 1). Approach All standard and minimally invasive approaches for exposure of the knee joint can be applied and supported with the navigation system. Ultrasound imaging should be obtained and aspiration of both hips should be done if septic hip arthritis is a concern. The liner is covered with a polished metal outer shell that articulates with the acetabular cartilage. The incision need not be in the interphalangeal crease to heal with an almost imperceptible scar. Here, too, the superficial peroneal nerve will be encountered and should be protected. Full range of motion starts 1 to 2 weeks postoperatively, and patients are advanced to plyometrics at 6 weeks postoperatively. Care should be taken to place the dressing deep within the commissure to avoid re-syndactylization during the healing process. Although type 3a can be converted to type 2b, the treatment would consist of four or more lengthenings. Accurately identifying and controlling pelvic position is crucial for evaluating hip extension and abduction range of motion. The use of square nuts or clickers on the connecting rods allows future distraction. With traction and manipulation of the pieces, the medial wall is reduced and pinned with axial Kirschner wires that travel just inside the medial wall of the calcaneus. Care should be taken to avoid nerve roots, which are present rostral and caudal to the pedicle walls of the hemivertebra. Late fixation failure is uncommon but can happen if flexion beyond 90 degrees is started too soon postoperatively. Most authors recommend 6 weeks of intravenous antibiotic therapy, although there is considerable variability in published reports, ranging from 0 to 9 weeks of intravenous antibiotics and none to more than 2 years of oral antibiotics. A functional outcome study of 134 cerebral palsy patients treated surgically showed that the average functional improvement was from use of the hand as a poor passive assist to use of the hand as a poor active assist. Alternately, both nails are inserted from the same side to avoid compromised skin (B). Since such films are poorly tolerated in an awake child, they are rarely obtained outside of the operating room. The gait cycle is on the horizontal axis, the internal moment on the vertical axis. I believe that the incidence of high-energy hindfoot trauma will increase over time. Although the intensity of the clinical symptoms may vary, they usually become more severe, more frequent, and more debilitating over time. A 4-cm incision is made over the palpable pes anserinus tendons on the medial side of the upper tibia.

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Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. The natural history of neuromuscular scoliosis is usually that of slow progression, beginning with the development of a flexible scoliosis in middle childhood and the more rapid development of a more fixed scoliosis during the adolescent growth spurt. The surgeon should protect the soft tissues posterior to the malleolus during the osteotomy. It is characterized by pain out of proportion that persists beyond a typical recovery timeframe and may also entail swelling, skin color changes, and limited range of motion. In simple syndactyly, adjacent digits are joined by varying amounts of skin and soft tissue. Diagnostic evaluation of the central compartment is performed with both a 70- and 30-degree arthroscope. Crego or Chandler retractors are then placed medially and laterally to protect the soft tissues. If a narrow skin bridge occurs between this approach and the fibular incision, this approach should be kept short (eg, 4 to 5 cm) and used for the articular reduction. Prepare the femur using the revision instrumentation particular to the system being used. In the coronal plane, the apex of the osteotomy starts 2 cm above the joint and is inclined toward the triradiate cartilage medially. An intact fibula may interfere with preparation of the tibia as it can limit mobilization of the proximal and distal fragments. Life expectancy in pediatric patients with cerebral palsy and neuromuscular scoliosis who underwent spinal fusion. The femoral component must be sized such that there is no over-reaming of the femur or risk of notching of the neck. Exposure of the lateral surface of proximal femur, with the vastus lateralis reflected anteriorly. Concerns about rotational stability after flexible nail stabilization seem to have been vastly overstated, and aboveelbow immobilization is not required. It has been said that you need only a thumb to test the motor function of all three major nerves: radial nerve extensor pollicis longus, ulnar nerve adductor pollicis, median nerve opponens pollicis. In the standard intramedullary techniques, the anatomic axes are used as guides to estimate the mechanical axis; in navigation-assisted technique, however, the mechanical axes are determined and cuts are made perpendicular to those axes. The details of fibular osteotomy and anterior compartment fasciotomy are the same. Persistent acetabular dysplasia, if present past age 7 years, is associated with a poor late outcome. However, radiographs do not demonstrate the actual size of the cartilaginous component. No matter what procedure is used for treating the radial dysplasia, the patients all have a high incidence of recurrent deformity as they get older. With the insidious deviation of the mechanical axis, secondary ligamentous laxity, patellofemoral instability, and joint subluxation may ensue, resulting in gait disturbance and functional limitations. With acetabular retroversion, theoretically greater unit loads are imposed on the available posterior cartilage, which may be responsible for the development of osteoarthritis of the hip. Meticulous skin closure, with excision of hypertrophic prior scar, if necessary, is carried out to minimize postoperative wound drainage. Note the near parallel orientation of the anterior and posterior (dashed line) acetabular walls. The long anterior thigh incision and intermuscular proximal release of the rectus femoris muscle must be performed. This can be achieved with a good suction-tight feel with placement of the trial component. The Prostalac molds are available in variety of sizes and lengths (120, 150, 200, and 240 mm).