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Deformities & Congenital

Congenital foot/hand deformities: CTEV, neurogenic clubfoot, radial deficiencies—diagnosis, classification, and treatment algorithms.

Overview

Congenital malformations represent the most common anomalies in upper extremities evaluated in population studies [1]. While treatment advances for these anomalies have historically progressed slowly through retrospective analyses [9], subjective data regarding function and aesthetics are increasingly available to guide care [9]. Nonsurgical management remains the initial choice for nearly all congenital foot deformities, with surgical intervention reserved for cases where conservative measures fail to relieve symptoms or improve function [7].

Surgical indications vary by specific pathology and patient presentation. Early corrective surgery is recommended for progressive or significant congenital isolated upper limb hypertrophy with hand abnormality [5], while surgery is advisable for children with congenital distal radius deformity presenting with increasing pain, deformity, or impaired daily activities regardless of age [12]. Re-operation may be required if recurrence occurs [12]. For complex and rigid congenital scoliosis in children younger than 10 years old, two-staged posterior osteotomy is an option [22], whereas posterior hemivertebra resection with unilateral instrumented fusion offers a simple, secure, and less-invasive technique to resolve the condition in this age group [27].

Specific anomalies require tailored approaches. Patients with Moebius syndrome present with a wide range of hand malformations necessitating careful evaluation to determine surgical need and optimize rehabilitation protocols [11]. Surgical procedures for rare anomalies like upper limb dimelia must be carefully selected [14], while the aim of surgery for triphalangeal thumb is to reconstruct anomalies for greater function and acceptable appearance [23]. For clinodactyly, closing wedge osteotomy of the abnormal middle phalanx is recommended for moderate (15° to 30°) and severe (30°) deformities [24].

Anatomy & Pathophysiology

Osseous and Joint Morphology

The clubfoot talus exhibits a markedly reduced anterior motion segment compared to the normal talus [79]. In hallux valgus, the severity of the deformity correlates positively with the magnitude of anteroposterior postural sway [70], while the hallux interphalangeus angle (HIA) shows a significant correlation with forefoot abduction-related parameters in juveniles [80]. Measurement techniques vary in sensitivity; hallux valgus angles derived from margo medialis pedis measurements are slightly but statistically significantly smaller than metatarsophalangeal hallux valgus angles, rendering them conservative estimates [83].

Kinematics and Gait

Three-dimensional gait analysis of children with clubfoot treated via the Ponseti method reveals distinctive but slight deviations [57]. Both nonoperatively and surgically treated clubfeet demonstrate significant limitations in ankle plantar flexion, resulting in decreased range of motion, moment, and power compared with controls [76]. Caution is required when interpreting changes in foot rotation in feet with higher degrees of rotation [55]. Furthermore, in children with spastic cerebral palsy and decreased dorsal ankle range of motion, the foot plate angle is not a reliable estimate of talocrural joint rotation because a sizable portion of the movement derives from internal foot deformation [77].

Functional Outcomes and Alignment

A plantigrade foot was achieved in 95% of feet initially treated with the Ponseti method for untreated clubfeet in Nepalese patients aged one to five years, yet residual deformities remained common even when plantigrade alignment was initially achieved [13]. Surgical treatment of symptomatic flat foot deformities in children significantly improves static segmental alignment and mediolateral foot loading but worsens fore-aft loading [53]. Children with flat feet perform poorer in certain physical performance tasks compared to counterparts with normal feet [74].

Pathophysiology and Surgical Indications

The pathophysiology of flexible adult acquired flatfoot deformity involves a mild, flexible deformity in early stages, necessitating early diagnosis to initiate treatment [66]. An unrecognized valgus deformity of the hindfoot is often unmasked during treatment of congenital metatarsus varus, potentially resulting in a pronated foot if not properly managed [69]. Surgical indications for spastic equinovarus foot deformity focus primarily on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot [71]. Hallux valgus is a common deformity with multiple surgical options tailored to specific characteristics such as joint congruency and intermetatarsal angle [78]. Clubfoot is not a single entity requiring uniform treatment; surgical methods must be selected based on a clear understanding of the specific anatomical and functional derangement in each foot [81].

Assessment Tools

A virtual 3D landmark palpation protocol provides an objective, reproducible tool for clubfoot assessment, bridging the gap between subjective clinical evaluation and quantitative morphometric analysis [82].

Classification

Swanson: The Swanson classification often lacks uniformity for complex upper limb anomalies, likely due to outdated pathogenesis knowledge [4]. Consequently, a new descriptive method is necessary to describe anomalies instead of diagnoses for complex upper limb anomalies [4].

Wassel: The Wassel classification system does not include the anomaly described as Wassel Type III Polydactyly With Symphalangism [6].

OMT: The OMT classification can be used to describe hand anomalies that may present in over 1,400 diseases [21]. The updated Oberg, Manske, and Tonkin (OMT) classification system is reasonably practical for precise classification of congenital upper-limb anomalies [36]. The ObergeManskeeTonkin classification system is recommended to replace the Swanson classification [37]. This recommendation cites increased knowledge of molecular etiology and the need for a system that describes the limb axis and specific anomalies [37].

PCFD: The new PCFD classification system offers an option to aid surgeons in approaching progressive collapsing foot deformity as a complex 3-dimensional deformity and individualizing treatment for each patient's unique anatomy [16]. However, the new PCFD classification system has room for improvement [16].

Thumb Duplication (C3): A proposed classification system for congenital thumb duplication type C3 is based on radiographic pathoanatomy and identifies four distinct subtypes of deformity [18]. This proposed classification system for congenital thumb duplication type C3 complements that of Wu et al. [18].

Ulnar Polydactyly: Complicated ulnar polydactyly and ulnar polydactyly with bifid proximal phalanx are two important types with surgical implications that are not both included in current classification systems [38]. A modified classification system is proposed to better define diagnosis and treatment plans for complicated ulnar polydactyly and ulnar polydactyly with bifid proximal phalanx [38].

Zuidam et al: The Zuidam et al classification diagram still needs more elaboration to describe some of the complex presentations of thumb polydactyly [40]. Despite this, the Zuidam et al classification diagram is considered the most comprehensive yet practical system available for thumb polydactyly [40].

Radial Polydactyly: A modified classification system for radial polydactyly including triphalangeal thumb and triplication is proposed as a practical and utilitarian scheme for nomenclature [44]. This modified classification system for radial polydactyly may assist comparison of treatment outcomes and individual cases [44].

Symbrachydactyly: A re-classification exercise for short finger and cleft type symbrachydactyly provides clearer definition of the different subtypes [45]. The re-classification of short finger and cleft type symbrachydactyly may give insight into the developmental biology of these conditions [45]. Furthermore, the re-classification of short finger and cleft type symbrachydactyly may predict future clinical function and guide surgical outcomes [45].

Fibular Deficiency: A simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening has been proposed [20]. This simplified classification for congenital fibular deficiency may be effectively applied in infancy to anticipate deformity and estimate treatment requirements [20].

Cervical Spine: No existing prognostic classification system can predict which patients with a congenital osseous anomaly of the cervical spine are at risk for future neurologic injury [19].

Other Considerations: An updated classification scheme for upper limb anomalies incorporating the molecular perspective of limb development and pathogenetic basis using dysmorphology terminology is advocated to improve diagnosis, treatment, and research [15]. A chapter provides a comprehensive overview of the assessment, classification, and treatment algorithms for pediatric lower extremity deformities and limb deficiencies [46]. This overview of pediatric lower extremity deformities includes limb-length discrepancy, angular deformities like Blount disease, rotational deformities, and limb deficiencies [46].

Clinical Presentation

Congenital anomalies of the upper extremity represent the most common congenital anomalies in evaluated populations [1]. Poland anomaly presents as a rare condition with distinct etiology and presentation patterns, though an atypical phenotype warrants consideration of alternative diagnoses or syndromes before confirming Poland syndrome [3, 48]. Patients with Moebius syndrome may similarly present with a wide spectrum of hand malformations [11]. While the Swanson classification is frequently utilized, it often lacks uniformity for complex congenital anomalies due to outdated pathogenesis knowledge [4]. Consequently, a new descriptive method is necessary to describe anomalies rather than rely on diagnoses for complex congenital upper limb anomalies [4]. An updated classification scheme incorporating the current molecular perspective of limb development is advocated to improve diagnosis, treatment, and research [15].

Specific entities often defy standard categorization. Wassel Type III polydactyly with symphalangism is a rare entity that does not fit into any type in the Wassel classification system [6]. The OMT classification can be used to describe hand anomalies that may present in over 1,400 diseases [21]. Macrodactyly of the foot is a rare congenital malformation with diverse clinical manifestations and multiple elements' involvement [42]. Multiple deformities in diastrophic dwarfism are often severe and highly resistant to corrective and reconstructive measures [41].

Management strategies vary by pathology and patient age. Nonsurgical treatment is the initial choice for almost all congenital foot deformities, with surgical treatment generally reserved for patients in whom nonsurgical measures fail to relieve symptoms or improve function [7]. Treatment of thumb hypoplasia involves identifying and addressing co-morbid anomalies, grading severity, and instituting appropriate treatment methods to provide a stable and functional thumb unit [43]. Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options [39]. A simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening may be effectively applied in infancy [20].

Deformity recurrence is common in arthrogryposis, particularly in skeletally immature patients [8]. The treatment of any type of arthrogryposis can be challenging [10]. While most tarsal bone coalitions are developmental and sporadic, syndromic coalitions occur as part of inherited complex skeletal malformations [47]. Rotational and angular limb deformities in children are common and generally fall within a physiologic range that resolves spontaneously [17]. The mainstays of treatment for pediatric rotational and angular limb deformities involve education, reassurance, and identifying pathologic causes through history and physical examination [17].

Investigations

Plain radiography: Malformations represent the most common congenital anomalies in the upper extremity [1]. While the Swanson classification is frequently utilized, it often lacks uniformity for complex anomalies due to outdated pathogenesis knowledge [4]. Consequently, anomalies should be described rather than diagnosed using a new descriptive method currently under validation [4]. Specific limitations exist within existing systems; for instance, Wassel Type III Polydactyly with Symphalangism does not fit into any type in the Wassel classification [6]. Newer radiographic systems have been proposed to address these gaps: a system for congenital thumb duplication type C3 based on radiographic pathoanatomy identifies four distinct subtypes [18], and a reliable system for synpolydactyly has been reported to improve clinician communication [63]. Additionally, the radiographic classification of fibrous dysplasia of the proximal femur is reproducible and useful for describing and assessing the disease [67]. The "kissing delta bone" is a critical radiographic clue for identifying syndromes, as every case presented with an associated syndrome or major congenital anomaly [73]. Radiographs should not be routinely obtained to assess nonoperatively corrected clubfoot at age 2 years [59].

MRI: MRI demonstrates a range of soft-tissue abnormalities, including unique patterns of specific muscle-compartment aplasia or hypoplasia. These patterns are present in patients with treatment-resistant clubfoot but absent in those with treatment-responsive clubfoot [56].

CT: Three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations, providing detailed abnormal vascular patterns and bony malformations [61].

Other Considerations: The new PCFD classification system offers an option to aid surgeons in approaching this complex three-dimensional deformity and individualizing treatment for each patient's unique anatomy [16]. No existing prognostic classification system can predict which patients with a congenital osseous anomaly of the cervical spine are at risk for future neurologic injury [19]. In rare cases of severe deformity, Harrington instrumentation may be used to gain correction provided a preoperative myelogram excludes spinal cord anomalies and cord function is monitored [60].

Treatment

Non-Operative

Nonsurgical treatment serves as the initial choice for almost all congenital foot deformities, with surgical intervention generally reserved for patients in whom these measures fail to relieve symptoms or improve function [7]. Early intervention utilizing proper nonsurgical and surgical management can achieve improvement in many patients with arthrogryposis [10]. Surgical growth-friendly treatment for skeletal dysplasia-associated early-onset scoliosis should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment [51].

Operative

Indications: Early corrective surgery is recommended for progressive or significant congenital upper limb hypertrophy with hand abnormality [5]. Surgery is advisable in children with congenital deformity of the distal radius presenting with increasing pain, deformity, or impaired daily activities regardless of age [12]. Patients with Moebius syndrome may present with a wide range of hand malformations requiring careful evaluation to determine the need for surgical treatment [11]. Treatment advances for congenital upper limb anomalies have progressed slowly using information from retrospective analyses and reports of evolving surgical techniques [9].

Surgical Approach / Technique: Closing wedge osteotomy of the abnormal middle phalanx is recommended for moderate (15° to 30°) and severe (30°) clinodactyly deformities [24]. The aim of surgical treatment for triphalangeal thumb is to reconstruct or correct anatomic anomalies to obtain greater function and a more acceptable appearance [23]. A two-staged posterior osteotomy surgery is an option for treatment of complex and rigid congenital scoliosis in children younger than 10 years old [22]. Posterior hemivertebra resection with unilateral instrumented fusion is a simple, secure, reliable, less-invasive, and well-tolerated technique that can successfully resolve congenital scoliosis in children less than 10 years old [27]. Isolated wedge osteotomy of the ulna seems to be safe and reliable in mild cases of Madelung's deformity [50]. Radialization has shown promise in early follow-up for severe radial longitudinal deficiency deformities [52]. The appropriate surgical procedure should be chosen for rare anomalies such as upper limb dimelia [14].

Other Considerations: Surgical treatment for congenital thumb hypoplasia is not contraindicated by forearm or wrist anomalies, though these anomalies significantly compromise functional results [58]. Re-operation may be needed for congenital deformity of the distal radius if there is a recurrence of deformity in the future [12]. Treatment for radial longitudinal deficiency remains controversial [52]. There is no consensus as to the best treatment for idiopathic congenital talipes equinovarus [64]. Subjective outcome information is becoming more readily available to guide future treatment for function and aesthetics in congenital upper limb anomalies [9]. Future study should focus on gathering objective outcomes data and providing guidance on the management of symptomatic Madelung deformity [54].

Complications

General Deformity Recurrence: Malformations represent the most common congenital anomalies in the upper extremities [1]. Deformity recurrence is frequent, particularly in skeletally immature patients [8]. Surgical reconstruction for radial longitudinal deficiency carries a high risk of recurrent deformity [33]. Residual deformities are common following the Ponseti method for untreated clubfeet, even when a plantigrade foot is initially achieved and maintained [13]. The revision rate for radial polydactyly reconstruction trends upward over time despite maintenance of favorable objective outcome scores [25].

Long-Term Outcomes and Quality of Life: Adults with sacral myelomeningocele have poorer long-term outcomes than children and do not uniformly do well, requiring continued orthopaedic care into adulthood [29]. Seventy percent of patients with congenital upper limb differences report deteriorating health-related quality of life with increasing age [30]. Congenital muscular torticollis does not resolve spontaneously if it persists beyond the age of one year [35].

Other Considerations: Thoracoplasty determines the occurrence of postoperative pulmonary complications in congenital scoliosis patients younger than 10 years old [87].

Recovery

Light activity (weeks): Specific timelines for light activity are not defined in the available evidence; however, surgery is advisable in children with increasing pain, deformity, or impaired daily activities regardless of age [12].

Full activity (months): No specific month ranges for full activity are provided in the evidence base. Long-term results after surgical reconstruction for radial polydactyly were excellent [25], though the revision rate for radial polydactyly reconstruction trended upward over time despite maintenance of favorable scores on objective outcome measures [25]. Correction following single osteotomy at the radial diaphysis for congenital radioulnar synostosis was maintained through midterm follow-up [26]. Long-term follow-up for type BIIIa rotationplasty in children shows good functional and oncological outcomes without the need for additional surgical procedures [62].

Complete recovery / outcome plateau (months): A plantigrade foot was achieved in 95% of feet initially in untreated clubfeet treated with the Ponseti method and followed for at least 10 years [13]. Residual deformities were common in patients with untreated clubfeet treated with the Ponseti method and followed for at least 10 years [13]. A greater delay in walking age may be expected for infants with idiopathic clubfoot treated using the Ponseti method who have a very severe deformity [85]. A greater delay in walking age may be expected for infants with idiopathic clubfoot treated using the Ponseti method who experience a deformity relapse [85]. Spontaneous recovery occurs in 60% to 90% of brachial plexus birth injury cases [33]. Congenital muscular torticollis does not resolve spontaneously if it persists beyond the age of one year [35]. Surgical reconstruction for radial longitudinal deficiency carries a high risk of recurrent deformity [33].

Rehabilitation protocol: Re-operation may be needed if there is a recurrence of deformity in the future [12]. Complications following single osteotomy at the radial diaphysis for congenital radioulnar synostosis were few [26].

Functional milestones: Outcomes for adults with sacral myelomeningocele are much poorer than those reported for children [29]. Adults with sacral myelomeningocele do not uniformly do well on a long-term basis [29]. 70% of patients with congenital upper limb differences reported deteriorating health-related quality of life with increasing age [30]. A realistic long-term goal for the management of early-onset scoliosis is spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation [72].

Other Considerations: Malformations were the most common congenital anomalies in the 653 upper extremities evaluated over a 1-year period at 3 institutions [1]. Treatment advances for congenital upper limb anomalies have progressed slowly using information from retrospective analyses and reports of evolving surgical techniques [9]. Subjective outcome information is becoming more readily available to guide future treatment for function and aesthetics in congenital upper limb anomalies [9]. Adults with sacral myelomeningocele need continued orthopaedic care into adulthood [29].

Key Evidence

  • [L3] Malformations were the most common congenital anomalies in the 653 upper extremities evaluated over a 1-year period at 3 institutions. (10.1016/j.jhsa.2014.10.038)
  • [L5] This update summarizes select articles pertaining to limb-lengthening and deformity correction published from January 1, 2013, to December 31, 2013, covering topics such as guided growth, congenital deficiencies, and surgical techniques. (10.2106/jbjs.n.00369)
  • [L4] Improved understanding the etiology and presentation of Poland anomaly can improve clinician recognition and management of this rare congenital condition. (10.1177/1558944716647355)
  • [L4] The Swanson classification often lacks uniformity for complex anomalies, likely due to outdated pathogenesis knowledge; therefore, it is necessary to describe anomalies instead of diagnoses using a new descriptive method currently being validated. (10.1054/jhsb.1999.0336)
  • [L4] The authors recommend early corrective surgery for progressive or significant deformities. (10.1054/jhsb.2001.0643)
  • [L4] The anomaly described does not fit into any type in the Wassel classification system. (10.1016/j.jhsa.2014.02.028)
  • [L5] Deformity recurrence is common, particularly in skeletally immature patients. (10.5435/00124635-200211000-00006)
  • [L4] Patients may present with a wide range of hand malformations, each patient should be carefully evaluated in order to determine whether surgical treatment is needed and to optimize rehabilitation protocols. (10.1177/1558944721994265)
  • [L4] Surgery is advisable in children with increasing pain, deformity or impaired daily activities regardless of age, although re-operation may be needed if there is a recurrence of deformity in the future. (10.1177/1753193408092491)
  • [L4] A plantigrade foot was achieved in 95% of the feet initially and was maintained in most of the patients, although residual deformities were common. (10.2106/jbjs.18.00445)
  • [L4] The appropriate surgical procedure should be chosen for a rare anomaly such as the present case. (10.1016/j.jhsa.2017.02.005)
  • [L5] The authors advocate an updated classification scheme for upper limb anomalies that incorporates the current molecular perspective of limb development and the pathogenetic basis for malformations using dysmorphology terminology to improve diagnosis, treatment, and research. (10.1016/j.jhsa.2010.09.031)
  • [L5] The new PCFD classification system offers an option to aid surgeons in approaching this complex 3-dimensional deformity and individualizing treatment for each patient's unique anatomy, although it has room for improvement. (10.5435/jaaos-d-24-01499)
  • [L3] The proposed system is based on radiographic pathoanatomy and complements that of Wu et al. by identifying four distinct subtypes of deformity. (10.1186/s12891-024-07916-x)
  • [L5] No existing prognostic classification system can predict which patients with a congenital osseous anomaly of the cervical spine are at risk for future neurologic injury. (10.2106/00004623-200202000-00017)
  • [L4] The authors propose a simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening, which may be effectively applied in infancy to anticipate deformity and estimate treatment requirements. (10.2106/jbjs.j.00683)
  • [L4] The OMT classification can be used to describe hand anomalies that may present in over 1,400 diseases. (10.1016/j.jhsa.2017.03.043)
  • [L4] This procedure can be an option of treatment for complex congenital scoliosis. (10.1186/s12891-021-04682-y)
  • [L4] The aim of surgical treatment is to reconstruct or correct the anatomic anomalies to obtain greater function and a more acceptable appearance. (10.1177/1753193418797922)
  • [L4] This treatment is recommended for moderate (15° to 30°) and severe (30°) deformities. (10.1016/j.jhsa.2009.01.007)
  • [L4] Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on the objective outcome measures used. (10.1016/j.jhsa.2014.05.006)
  • [L4] Complications were few, and the correction was maintained through midterm follow-up. (10.1016/j.jhsa.2014.05.018)
  • [L4] The authors conclude it is a simple, secure, reliable, less-invasive, and well-tolerated technique that can successfully resolve this kind of congenital scoliosis in children. (10.1186/s13018-018-0946-3)
  • [L4] The outcomes for adults who have a sacral myelomeningocele seem to be much poorer than those reported for children; they do not uniformly do well on a long-term basis and they need continued orthopaedic care into adulthood. (10.2106/00004623-199409000-00003)
  • [L4] This commentary highlights that congenital upper limb differences must never be underestimated regarding their functional impact during maturation and aging, as 70% of patients reported deteriorating health-related quality of life with increasing age. (10.1177/17531934231164093)
  • [L4] Congenital muscular torticollis does not resolve spontaneously if it persists beyond the age of one year. (10.2106/00004623-198264060-00002)
  • [L4] The updated OMT classification system is reasonably practical for precise classification of these anomalies. (10.1016/j.jhsa.2023.05.016)
  • [L5] The paper recommends the adoption of the ObergeManskeeTonkin classification system to replace the Swanson classification, citing increased knowledge of molecular etiology and the need for a system that describes the limb axis and specific anomalies. (10.1016/j.jhsa.2014.12.001)
  • [L4] Complicated ulnar polydactyly and ulnar polydactyly with bifid proximal phalanx are two important types with surgical implications that are not both included in current classification systems; the authors propose a modified classification system to better define diagnosis and treatment plans for these conditions. (10.1016/j.jhsa.2014.12.030)
  • [L5] Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options. (10.5435/00124635-200606000-00005)
  • [L5] The Zuidam et al classification diagram still needs more elaboration to describe some of the complex presentations of thumb polydactyly, although the author agrees it is the most comprehensive yet practical system available. (10.1016/j.jhsa.2009.10.009)
  • [L4] However, the multiple deformities are often severe and highly resistant to corrective and reconstructive measures. (10.2106/00004623-196850010-00007)
  • [L4] Macrodactyly of the foot is a rare congenital malformation with diverse clinical manifestations and multiple elements' involvement. (10.1186/s13018-020-02196-2)
  • [L5] Treatment of thumb hypoplasia involves identifying and addressing co-morbid anomalies, grading severity, and instituting appropriate treatment methods to provide a stable and functional thumb unit. (10.1016/j.jhsa.2009.07.020)
  • [L2] We propose a modified classification that is a practical and utilitarian scheme for nomenclature of radial polydactyly and that may assist comparison of treatment outcomes and individual cases. (10.1016/j.jhsa.2007.12.012)
  • [L4] This re-classification exercise provides clearer definition of the different subtypes and may give insight into the developmental biology of these conditions, predict future clinical function and guide surgical outcomes. (10.1177/17531934251318222)
  • [L4] While most cases are developmental and sporadic, syndromic coalitions occur as part of inherited complex skeletal malformations. (10.5435/jaaos-d-24-01191)
  • [L4] Therefore, in patients with an atypical phenotype, we recommend considering other diagnoses and/or syndromes before diagnosing a patient with Poland syndrome. (10.1016/j.jhsa.2017.08.029)
  • [L4] This technique seems to be safe and reliable in mild cases of Madelung's deformity. (10.1016/j.jhsa.2007.05.015)
  • [L3] Surgical growth-friendly treatment for skeletal dysplasia-associated EOS should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment. (10.1302/0301-620x.106b6.bjj-2023-1417.r2)
  • [L4] Treatment for radial longitudinal deficiency remains controversial, but radialization has shown promise in early follow-up for severe deformities, while children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability. (10.2106/jbjs.22.01323)
  • [L4] Surgical treatment resulted in significantly improved static segmental alignment and mediolateral foot loading, but worsened fore-aft loading. (10.1302/0301-620x.95b5.30594)
  • [L5] Future study should focus on gathering objective outcomes data and providing guidance on the management of symptomatic Madelung deformity. (10.5435/00124635-201306000-00007)
  • [L4] However, caution is needed when interpreting changes in foot rotation in feet with higher degrees of rotation. (10.1186/s12891-022-05465-9)
  • [L4] MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. (10.2106/jbjs.m.01257)
  • [L2] Three-dimensional gait analysis demonstrated distinctive but slight deviations. (10.2106/jbjs.m.01603)
  • [L4] Forearm/wrist anomalies significantly compromise functional results but are not a contraindication for pollicization. (10.1177/1753193414535177)
  • [L3] Such radiographs should not be routinely obtained for this purpose. (10.2106/jbjs.16.00693)
  • [L4] In rare cases of severe deformity, Harrington instrumentation may be used to gain correction provided a preoperative myelogram excludes spinal cord anomalies and cord function is monitored. (10.2106/00004623-198163040-00011)
  • [L4] Three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations, providing detailed abnormal vascular patterns and bony malformations. (10.1177/1753193420954357)
  • [L4] Long-term follow-up shows good functional and oncological outcomes, without the need for additional surgical procedures. (10.1302/0301-620x.108b1.bjj-2025-0309.r1)
  • [L4] This manuscript reports a new, reliable radiographic classification system for synpolydactyly that will allow improved communication between clinicians and serve as a foundation for future investigations. (10.1177/1753193417728710)
  • [L5] The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment. (10.5435/00124635-200207000-00002)
  • [L5] The article discusses the pathophysiology, classification, and treatment options for flexible adult acquired flatfoot deformity, emphasizing the controversy regarding the best surgical technique and the need for early diagnosis to initiate treatment while the deformity is mild and flexible. (10.1007/s00167-009-1015-6)
  • [L4] This radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease. (10.1186/s13018-015-0313-6)
  • [L4] The presence of an unrecognized valgus deformity of the hind part of the foot is often unmasked during treatment, potentially resulting in a pronated foot if not properly managed. (10.2106/00004623-196446030-00006)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L5] Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot. (10.5435/jaaos-d-23-01007)
  • [L4] A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation. (10.2106/jbjs.16.00796)
  • [L4] The kissing delta bone is an important clue to identifying a syndrome, as every case had a syndrome or a major congenital anomaly associated with it. (10.1054/jhsb.2001.0713)
  • [L4] This study shows that children with flat feet performed poorer in some physical performance tasks, compared to the normal feet counterparts. (10.1186/s12891-023-06752-9)
  • [L3] Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. (10.2106/jbjs.18.00317)
  • [L4] In SCP children diagnosed with decreased dorsal ROM of the ankle joint, the commonly used measure (i.e. range of foot plate angle), is not a good estimate of rotation at the talocrural joint since a sizable part of the movement of the foot derives from internal deformation of the foot. (10.1186/1471-2474-14-365)
  • [L3] One of the most pronounced and clinically relevant difference of the clubfoot talus compared to the normal talus is the markedly reduced anterior talar motion segment. (10.1186/s12891-021-04193-w)
  • [L3] The significant correlation between HIA and forefoot abduction-related parameters in juveniles highlights the need for a comprehensive assessment and treatment of combined deformities in managing juvenile-onset hallux valgus. (10.1186/s13018-024-05408-1)
  • [L4] Club foot is not a single entity requiring a uniform treatment; surgical methods must be selected based on a clear understanding of the specific anatomical and functional derangement in each foot. (10.2106/00004623-196749080-00021)
  • [L5] It provides orthopedic clinicians with an objective, reproducible tool for clubfoot assessment, bridging the gap between subjective clinical evaluation and quantitative morphometric analysis. (10.1186/s12891-026-09646-8)
  • [L4] Because the hallux valgus angles based on margo medialis pedis measurements were slightly but statistically significantly smaller, these measurements should be considered conservative estimates of the metatarsophalangeal angle. (10.1186/1471-2474-15-133)
  • [L4] A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse. (10.2106/jbjs.m.01525)
  • [L3] For congenital scoliosis patients younger than 10 years old, thoracoplasty determines the occurrence of postoperative pulmonary complications. (10.1186/s12891-022-05033-1)

See Also

References

[1] Epidemiology of Congenital Upper Limb Anomalies in a Midwest United States Population: An Assessment Using the Oberg, Manske, and Tonkin Classification. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.10.038

[2] What’s New in Limb-Lengthening and Deformity Correction. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.n.00369

[3] Presentation and Treatment of Poland Anomaly. HAND. 2016. DOI: 10.1177/1558944716647355

[4] Classification of Congenital Anomalies of the Upper Limb. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0336

[5] Congenital Isolated Upper Limb Hypertrophy with Hand Abnormality—A Report of 2 Cases. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0643

[6] Wassel Type III Polydactyly With Symphalangism: A Rare Entity. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.028

[7] Chapter 28 Congenital Disorders of the Foot. 2020.

[8] Arthrogryposis and Amyoplasia. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200211000-00006

[9] Chapter 20 Congenital Upper Limb Differences. 2020.

[10] Chapter 16 Arthrogrypotic Syndromes. 2020.

[11] Prevalence of Hand Malformations in Patients With Moebius Syndrome and Their Management. HAND. 2021. DOI: 10.1177/1558944721994265

[12] Re: A child with a congenital deformity of the distal radius that was corrected using the Ilizarov apparatus. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408092491

[13] Outcomes of the Ponseti Method for Untreated Clubfeet in Nepalese Patients Seen Between the Ages of One and Five Years and Followed for at Least 10 Years. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00445

[14] Upper Limb Dimelia. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.02.005

[15] Developmental Biology and Classification of Congenital Anomalies of the Hand and Upper Extremity. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.09.031

[16] So What Exactly Is Progressive Collapsing Foot Deformity?. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01499

[17] Chapter 29 Rotational and Angular Limb Deformity. 2020.

[18] Radiographic features and subtypes of congenital thumb duplication type C3 according to Wu et al. and their potential implications for surgical management: new classification and preliminary results. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07916-x

[19] Congenital Osseous Anomalies of the Upper and Lower Cervical Spine in Children. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200202000-00017

[20] Congenital Fibular Deficiency. The Journal of Bone & Joint Surgery. 2011. DOI: 10.2106/jbjs.j.00683

[21] Identification of Associated Genes and Diseases in Patients With Congenital Upper-Limb Anomalies: A Novel Application of the OMT Classification. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.043

[22] Two-staged posterior osteotomy surgery in complex and rigid congenital scoliosis in younger than 10 years old children. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04682-y

[23] Triphalangeal thumb: clinical features and treatment. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418797922

[24] Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.007

[25] Long-Term Outcomes Following Radial Polydactyly Reconstruction. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.006

[26] Single Osteotomy at the Radial Diaphysis for Congenital Radioulnar Synostosis. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.018

[27] Posterior hemivertebra resection with unilateral instrumented fusion in children less than 10 years old: preliminary results at minimum 5-year follow-up. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0946-3

[29] Myelomeningocele at the sacral level. Long-term outcomes in adults.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199409000-00003

[30] Age-related changes in patients with upper limb thalidomide embryopathy in the United Kingdom. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231164093

[33] Chapter 26 Congenital Hand and Wrist Differences and Brachial Plexus Birth Injury. 2019.

[35] Congenital muscular torticollis. A long-term follow-up.. The Journal of Bone & Joint Surgery. 1982. DOI: 10.2106/00004623-198264060-00002

[36] Epidemiology of Congenital Upper-Limb Anomalies in Southern Taiwan Based on the Updated Oberg, Manske, and Tonkin Classification: A Series of 1,335 Anomalies in 1,188 Patients. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.05.016

[37] Classification of Congenital Anomalies of the Hand and Upper Limb. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.001

[38] A Classification System for Ulnar Polydactyly and Clinical Series. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.030

[39] The Hypoplastic Thumb. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200606000-00005

[40] Congenital Hand Differences. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.10.009

[41] Diastrophic Dwarfism. The Journal of Bone & Joint Surgery. 1968. DOI: 10.2106/00004623-196850010-00007

[42] Clinical characteristics of 93 cases of isolated macrodactyly of the foot in children. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-020-02196-2

[43] Thumb Hypoplasia. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.07.020

[44] A Classification System of Radial Polydactyly: Inclusion of Triphalangeal Thumb and Triplication. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.012

[45] Revisiting short finger and cleft type symbrachydactyly subtype differentiation utilizing the congenital upper limb differences (CoULD) registry. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251318222

[46] Chapter 135 Pediatric Lower Extremity Deformities and Limb Deficiencies. 2019.

[47] Associated Coalitions of Tarsal Bones: Review of the Literature and Presentation of a Classification. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01191

[48] Controversies in Poland Syndrome: Alternative Diagnoses in Patients With Congenital Pectoral Muscle Deficiency. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.08.029

[50] Isolated Wedge Osteotomy of the Ulna for Mild Madelung’s Deformity. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.05.015

[51] Outcomes after completing growth-friendly surgical treatment for early-onset scoliosis in patients with skeletal dysplasia. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b6.bjj-2023-1417.r2

[52] Congenital Upper-Limb Differences. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.01323

[53] The operative correction of symptomatic flat foot deformities in children. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b5.30594

[54] Madelung Deformity. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201306000-00007

[55] The foot drawing method: reliability of measuring foot length and outward rotation in children with clubfoot. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05465-9

[56] Soft-Tissue Abnormalities Associated with Treatment-Resistant and Treatment-Responsive Clubfoot. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01257

[57] Results of Gait Analysis Including the Oxford Foot Model in Children with Clubfoot Treated with the Ponseti Method. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01603

[58] The results of pollicization for congenital thumb hypoplasia. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414535177

[59] Nonoperatively Corrected Clubfoot at Age 2 Years. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.00693

[60] Surgical treatment of congenital scoliosis with or without Harrington instrumentation.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163040-00011

[61] Three-dimensional CT angiography for surgical planning in congenital hand malformations: a case series presentation. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420954357

[62] Outcomes of type BIIIa rotationplasty in children. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0309.r1

[63] Sixth annual Paul R. Manske Award for the best upper-extremity congenital research manuscript. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193417728710

[64] Idiopathic Congenital Talipes Equinovarus. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200207000-00002

[66] Operative management options for symptomatic flexible adult acquired flatfoot deformity: a review. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-009-1015-6

[67] Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0313-6

[69] Recurrence in Congenital Metatarsus Varus. The Journal of Bone & Joint Surgery. 1964. DOI: 10.2106/00004623-196446030-00006

[70] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[71] Spastic Equinovarus Foot Deformity. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01007

[72] Functional and Radiographic Outcomes Following Growth-Sparing Management of Early-Onset Scoliosis. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.00796

[73] Duplicated Longitudinal Bracketed Epiphysis ‘Kissing Delta Phalanx’ in the Hand. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2001.0713

[74] Are flat feet a disadvantage in performing unilateral and bilateral explosive power and dynamic balance tests in boys? A school-based study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06752-9

[76] Functional Outcomes Following Treatment for Clubfoot. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00317

[77] Movement within foot and ankle joint in children with spastic cerebral palsy: a 3-dimensional ultrasound analysis of medial gastrocnemius length with correction for effects of foot deformation. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-365

[78] Chapter 110 Disorders of the First Ray. 2019.

[79] Radiological tarsal bone morphology in adolescent age of congenital clubfeet treated with the Ponseti method. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04193-w

[80] Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05408-1

[81] The Role of Surgery in the Treatment of Club Feet. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749080-00021

[82] Virtual 3D landmark palpation in clubfoot: feasibility of an innovative standardized morphometric protocol. A preliminary study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09646-8

[83] The hallux valgus angle of the margo medialis pedis as an alternative to the measurement of the metatarsophalangeal hallux valgus angle. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-133

[85] Walking Age of Infants with Idiopathic Clubfoot Treated Using the Ponseti Method. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01525

[87] Risk factors of postoperative pulmonary complications after primary posterior fusion and hemivertebra resection in congenital scoliosis patients younger than 10 years old: a retrospective study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05033-1

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