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.

Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years.

PURPOSE: To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF). METHODS: This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed. RESULTS: In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed. CONCLUSION: Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses. LEVEL OF EVIDENCE: Level II - prognostic study.

A systematic review of reported outcomes following Ponseti correction of idiopathic club foot.

AIMS: To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot. METHODS: A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper. RESULTS: In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function. CONCLUSIONS: There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step.Cite this article: Bone Joint Open 2020;1-8:457-464.

The efficacy of guided growth as an initial strategy for Blount disease treatment.

PURPOSE: The aim of this study was to evaluate the success of guided growth by temporal hemiepiphysiodesis of the lateral proximal tibia as a first line treatment option for Blount disease. METHODS: This was a retrospective multicentre study conducted in five centres, covering data on 55 limbs in 45 patients, with an average follow-up of 24.5 months following plate insertion. Preoperative alignment analysis was compared with three measurements taken postoperatively. The normalization of the mechanical medial proximal tibia angle (mMPTA) was defined as the primary outcome measure. RESULTS: Mean age at surgery was 9.5 years. Average preoperative mMPTA was 77°. On average, at 24.5 months post-surgery, mMPTA was 86.33°, while 43/55 limbs (78.18%) have achieved normalization (mMPTA 85° to 90°). Average rate of correction was 1° per month. When grouping the children as infantile (11 limbs), juvenile (12 limbs) and adolescent (32 limbs), operated on before the age of four years, between four and ten years and after the age of ten years, respectively, 63.63%, 66.67%, 87.5% have completed correction of deformity during the follow-up period. Interestingly, the femoral component of the deformity has achieved correction as well in 33/55 limbs (64%). CONCLUSION: Hemiepiphysiodesis is an effective first line treatment for Blount disease. Overall success rate is good but varies according to child's age. Adolescent Blount has the best chance of achieving full correction while same treatment is less effective in infantile Blount.Level of evidence: IV.

The effect of growth hormone treatment in a child with tricho-rhino-phalangeal syndrome: A case report and review of the literature.

Tricho-rhino-phalangeal syndrome (TRPS) is characterized by craniofacial and skeletal malformations including short stature, cone-shaped phalangeal epiphyses and Perthes-like changes of the hip. We describe the response to growth hormone (GH) treatment in a boy with TRPS. The patient presented at age 3.5 years for evaluation of short stature (-3.2SD). On physical examination, the characteristic facial phenotype of TRPS was noted. Radiographs showed cone-shaped phalangeal epiphyses and bilateral small and fragmented femoral heads. The diagnosis was confirmed by Sanger sequencing of the TRPS1 gene. Two GH stimulation tests revealed GH deficiency, and GH treatment was initiated. Subsequently, growth velocity improved, as did the radiographic appearance of the femoral epiphyses, as seen on sequential pelvis radiographs. This observation suggests the possibility of a beneficial effect of GH treatment on both height and epiphyses status in TRPS patient with GH deficiency. Further studies are needed to support the observation.

Surgical Treatment of Congenital and Obligatory Dislocation of the Patella in Children.

BACKGROUND: Congenital (fixed) dislocations and obligatory (habitual) patellar dislocations represent a complex clinical and surgical challenge. Numerous treatment options, offering different perspectives, and surgical solutions are reported in the literature.We implemented the surgical technique principles, originally described by Stanisavljevic, for congenital (fixed) and obligatory (habitual) patellar dislocations, with slight modifications. METHODS: We retrospectively evaluated the results of group of 12 patients (15 knees), operated between the years 2002 and 2013. The procedure includes extensive subperiosteal quadriceps realignment and soft tissue medial plication, followed by distal realignment through patellar tendon splitting. The outcome measures were patellar stability, knee range of motion, Pedi-IKDC knee function score, and the PODCI global function score. RESULTS: The study group included 12 patients, 9 females and 3 males (15 knees) whose mean age was 5 years 2 months at diagnosis and 7 years 5 months at surgery. Nine patients had an underlying diagnosed genetic background [Down syndrome (n=6), Larsen syndrome (n=2), nail-patella syndrome (n=1)]. The mean follow-up was 46.2 months. Eleven patients, gained stable patella with no recurrence of dislocation. Postoperative knee active extension was improved significantly (P<0.0001) for all patients. The average postoperative Pedi-IKDC and PODCI scores were significantly higher (P<0.001) among the idiopathic group. CONCLUSIONS: These results suggest that the Stanisavljevic procedure principles with modifications, provides an efficient method for treatment of fixed and obligatory patellar dislocation. In our opinion, young age at surgery played an important role in the surgical outcome. LEVEL OF EVIDENCE: Level IV-therapeutic.

Bone-Grafting in Polyostotic Fibrous Dysplasia.

BACKGROUND: Polyostotic fibrous dysplasia is a skeletal disease that results from somatic activating mutations in the gene GNAS in skeletal stem cells, leading to proliferation of immature osteogenic cells with replacement of normal marrow and bone with fibro-osseous tissue. Lesions may cause bone deformity or fracture. In the surgical care of polyostotic fibrous dysplasia, the role of grafting and the optimal grafting material are not clear. The purpose of this study was to evaluate the long-term survival of bone-grafting procedures in subjects with polyostotic fibrous dysplasia over time. METHODS: The operative reports and radiographs of a cohort of subjects with polyostotic fibrous dysplasia followed in a natural history study were reviewed. Twenty-three subjects (mean age at the time of enrollment, thirteen years [range, two to forty years]) with fifty-two bone-grafting procedures had a mean follow-up time of 19.6 years (range, twenty-nine months to forty-seven years). Kaplan-Meier life table estimates, Cox proportional hazard models, and t tests comparing means were performed to assess various aspects of graft survival. RESULTS: Kaplan-Meier curves showed a 50% estimate of survival of 14.5 years. Cox proportional hazards models showed no advantage comparing allograft with autograft or structural with nonstructural graft materials. The mean age of the patients was significantly greater (p < 0.001) in the subgroup of subjects in whom grafts were maintained over time (20.9 years) compared with the subgroup of patients whose grafts were resorbed over time (9.8 years). CONCLUSIONS: Bone-grafting, including both allograft and autograft, is of limited value in ablating the lesions of fibrous dysplasia. The expectations of patients and surgeons should include the high probability of graft resorption over time with return of bone characteristics of fibrous dysplasia, particularly in younger patients. This suggests the maintenance of normal bone mechanics with implant support should be the priority of any surgical intervention.

Radiographic Indicators of Surgery and Functional Outcome in Ponseti-Treated Clubfeet.

BACKGROUND: Evaluation of the results of treatment for clubfoot by the Ponseti technique is based on clinical and functional parameters. There is a need to establish universally recognized quantitative measurements to compare, better understand, and more precisely evaluate therapeutic outcome. METHODS: Nine angles were measured on standard radiographs of 145 children with idiopathic clubfeet treated between 2000 and 2010 with the Ponseti method. The average follow-up was 6.3 years. The need for additional surgery and the functional outcome was correlated to the radiologic measurements. RESULTS: Three radiologic parameters were identified as having significant (P ≤ .001) predictive value. The lateral tibiocalcaneal angle with the ankle at maximal dorsiflexion measuring fixed equinus was larger in the preoperated group (77 ± 12 degrees) compared to the nonoperated group (67 ± 14 degrees). Functional outcome was better with smaller angles. The lateral talocalcaneal angle with the ankle at maximal dorsiflexion measuring hindfoot rigidity was smaller (29 ± 8 degrees) in the preoperated group compared to the nonoperated group (35 ± 9 degrees). Functional outcome was better with larger angles. The lateral talo-first metatarsal angle with the ankle at maximal plantarflexion measuring foot cavus was larger in the preoperated group (31 ± 10 degrees) compared to the nonoperated group (22 ± 11 degrees), whereas functional outcome did not correlate with this angle. CONCLUSIONS: The lateral view with the foot in maximal dorsiflexion was found to be the most significant and useful view to detect abnormality in Ponseti-treated clubfeet. In our practice now, we are using only this view in order to reduce the radiation exposure to the child. LEVEL OF EVIDENCE: Level III, retrospective case series.

Are Gait Indices Sensitive Enough to Reflect the Effect of Ankle Foot Orthosis on Gait Impairment in Cerebral Palsy Diplegic Patients?

BACKGROUND: Neuromuscular impairments may compromise gait function in patients with cerebral palsy (CP). As such, ambulatory children with CP often use ankle foot orthosis (AFO) to facilitate and optimize their ability to walk.The aim of this study was to evaluate whether the different gait indices, the Gillette Gait Index (GGI), the Gait Deviation Index (GDI), and the Gait Profile Score (GPS), reflect the improved gait that was previously shown using AFO. METHODS: A retrospective analysis of 53 studies on children with spastic diplegic CP. All had undergone a comprehensive gait study and were analyzed while walking, both barefoot and with their braces, in the same session.Kinematic and temporal spatial data were determined and summarized by 3 methods: GPS, GDI, and GGI. RESULTS: Significant differences were found between the barefoot condition and the AFO conditions for temporal and kinematic parameters: changes in GGI, GDI, and GPS were not statistically significant, with an improvement of 9.33% in GGI (P=0.448) and no change in GDI and GPS. CONCLUSIONS: The use of AFO in diplegic CP children caused a statistically significant improvement in temporal and kinematic parameters. Interestingly, it was found that this improvement was not reflected by GGI, GDI, or GPS.These findings might suggest that gait indices, as outcome measures, may sometimes not reflect all the effects of specific interventions. LEVEL OF EVIDENCE: Level III-retrospective study.

Influence of orthosis on the foot progression angle in children with spastic cerebral palsy.

We retrospectively assessed the effect of ankle-foot orthosis (AFO) on the foot progression angle (FPA) of 97 children with spastic cerebral palsy (CP) who had undergone comprehensive computer-based gait analysis both barefoot and with their orthosis, during the same session. The physical examination results and the gait study temporal and kinematic parameters comprise the study data. We focused on the peak FPA reached during stance and swing phases and at mid-stance and mid-swing, and also measured the transverse rotations of the pelvis, the femur and the tibia. AFOs improved gait, as reflected by improved temporal parameters, but they also increased internal rotation of the feet in diplegic CP children by 4.29 degrees for mid-stance, and by 3.72 degrees for mid-swing. The correlation between components of the rotational profile and FPA was significant for the diplegic group. AFOs did not produce any noteworthy differences between walking barefoot and walking with the brace in the hemiplegic group in what concerns FPA. Children with diplegic CP who use AFOs walk with increased internal FPAs in their orthoses. These findings might be explained by anatomical attributes as well as dynamic features during gait.

Congenital tibial pseudarthrosis, changes in treatment protocol.

Ten children with congenital pseudarthrosis of the tibia were treated with resection of pathologic bone, bone grafting, intramedullary rodding, compression with circular frame, simultaneous proximal tibia lengthening, and bone morphologic proteins. Thirteen operations were performed to achieve union. Four patients underwent simultaneous lengthening and four patients received recombinant human bone morphologic protein. Six children required complementary operations for residual ankle and knee valgus, and shortening. Union of the pseudarthrosis was achieved in all cases with lengthening up to 5 cm. This protocol is effective in achieving union of congenital pseudarthrosis of tibia; attention should be paid to the ankle joint to achieve functionality of the limb.

A functional electrical stimulation system improves knee control in crouch gait.

BACKGROUND: Crouch gait is a major sagittal plane deviation in children diagnosed with cerebral palsy (CP). It is defined as a combination of excessive ankle dorsiflexion and knee and hip flexion throughout the stance phase. To the best of our knowledge, functional electrical stimulation (FES) has not been used to decrease the severity of crouch gait in CP subjects and assist in achieving lower limb extension. PURPOSE: To evaluate the short- and long-term effects of FES to the quadriceps muscles in preventing crouch gait and achieving ankle plantar flexion, knee and hip extension at the stance phase. METHODS: An 18-year-old boy diagnosed with CP diplegia [Gross Motor Function Classification System (GMFCS) level II] was evaluated. The NESS L300(®) Plus neuroprosthesis system provided electrical stimulation of the quadriceps muscle. A three-dimensional gait analysis was performed using an eight-camera system measuring gait kinematics and spatiotemporal parameters while the subject walked shod only, with ground reaction ankle foot orthotics (GRAFOs) and using an FES device. RESULTS: Walking with the FES device showed an increase in the patient's knee extension at midstance and increased knee maximal extension at the stance phase. In addition, the patient was able to ascend and descend stairs with a "step-through" pattern immediately after adjusting the FES device. CONCLUSIONS: This report suggests that FES to the quadriceps muscles may affect knee extension at stance and decrease crouch gait, depending on the adequate passive range of motion of the hip, knee extension, and plantar flexion. Further studies are needed in order to validate these results.

A randomized, double blind, placebo-controlled trial of alendronate treatment for fibrous dysplasia of bone.

CONTEXT: Fibrous dysplasia (FD) is a rare skeletal disorder, resulting in deformity, fracture, functional impairment, and pain. Bisphosphonates have been advocated as a potential treatment. OBJECTIVE: To determine the efficacy of alendronate for treatment of FD. DESIGN: Two-year randomized, double-blind, placebo-controlled trial. SETTING: Clinical research center. PATIENTS: Forty subjects with polyostotic FD (24 adults, 16 children). Subjects were randomized and stratified by age. INTERVENTIONS: Study drug was administered over a 24 month period in 6 month cycles (6 months on, 6 months off). Alendronate dosing was stratified: 40 mg daily for subjects >50 kg, 20 mg for 30-50 kg, 10 mg for 20-30 kg. MAIN OUTCOME MEASURES: Primary endpoints were bone turnover markers, including serum osteocalcin, and urinary NTX-telopeptides. Secondary endpoints included areal bone mineral density (aBMD), pain, skeletal disease burden score, and functional parameters including the 9-min walk test and manual muscle testing. RESULTS: Clinical data was collected on 35 subjects who completed the study. There was a decline in NTX-telopeptides in the alendronate group (P = .006), but no significant difference in osteocalcin between groups. The alendronate group had an increase in areal BMD in normal bone at the lumbar spine (P = .006), and in predetermined regions of FD (P < .001). There were no significant differences in pain scores, skeletal disease burden scores, or functional parameters between the groups. CONCLUSIONS: Alendronate treatment led to a reduction in the bone resorption marker NTX-telopeptides, and improvement in aBMD, but no significant effect on serum osteocalcin, pain, or functional parameters.

Successful conservative treatment for neglected rotatory atlantoaxial dislocation.

BACKGROUND: Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively. METHODS: All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months. RESULTS: All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo). CONCLUSIONS: Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset. LEVEL OF EVIDENCE: Level IV (retrospective case series).

The efficacy of neuroprosthesis in young hemiplegic patients, measured by three different gait indices: early results.

PURPOSE: To evaluate functional electrical stimulation (FES) neuroprothesis as a method to improve gait in hemiplegic patients, using three different gait scoring methods as measures. METHODS: Five hemiplegic patients (four with cerebral palsy at GMFCS I, one with diffuse pontine glioma) with a mean age of 16.5 years were given a FES neuroprosthesis (NESS(®) L300™) that was applied and calibrated individually. After an adaptation period during which the participants increased their daily use of the neuroprosthesis, gait was assessed with the stimulation off and with the FES on. Kinematic, kinetic, and temporal spatial data were determined using motion analysis and summarized by three scoring methods: Gait Profile Score (GPS), Gait Deviation Index (GDI), and Gillette Gait Index (GGI). Indices were calculated using the Gaitabase program available online. Patients were followed for a minimum of 1 year. RESULTS: When comparing gait with and without stimulation, all scoring methods showed improvement. GPS and GDI of the affected leg were significantly improved: 12.23-10.23° (p = 0.017) and 72.36-78.08 (p = 0.002), respectively. By applying the movement analysis profile, the decomposed GPS score, we found that only the ankle dorsiflexion and the foot progression angle were significantly changed. GGI of the affected leg showed improvement, but without statistical significance: 168.88-131.64 (p = 0.221). Total GPS of legs and the GPS, GDI, and GGI of the nonaffected leg showed improvement without statistical significance. At the 1-year follow-up, all patients expressed high satisfaction and continued to use the device. CONCLUSIONS: Dorsiflexion functional electrical stimulation improves gait in hemiplegic patients, as reflected by GPS, GDI, and GGI.

Orthopedic surgeons' and neurologists' attitudes towards second opinions in the Israeli healthcare system: a qualitative study.

BACKGROUND: Second opinion is a treatment ratification tool that may critically influence diagnosis, treatment, and prognosis. Second opinions constitute one of the largest expenditures of the supplementary health insurance programs provided by the Israeli health funds. The scarcity of data on physicians' attitudes toward second opinion motivated this study to explore those attitudes within the Israeli healthcare system. METHODS: We interviewed 35 orthopedic surgeons and neurologists in Israel and qualitatively analyzed the data using the Grounded Theory approach. RESULTS: As a common tool, second opinion reflects the broader context of the Israeli healthcare system, specifically tensions associated with health inequalities. We identified four issues: (1) inequalities between central and peripheral regions of Israel; (2) inequalities between private and public settings; (3) implementation gap between the right to a second opinion and whether it is covered by the National Health Insurance Law; and (4) tension between the authorities of physicians and religious leaders. The physicians mentioned that better mechanisms should be implemented for guiding patients to an appropriate consultant for a second opinion and for making an informed choice between the two opinions. CONCLUSIONS: While all the physicians agreed on the importance of the second opinion as a tool, they raised concerns about the way it is provided and utilized. To be optimally implemented, second opinion should be institutionalized and regulated. The National Health Insurance Law should strive to provide the mechanisms to access second opinion as stipulated in the Patient's Rights Law. Further studies are needed to assess the patients' perspectives.

Patient-physician relationships in second opinion encounters - the physicians' perspective.

Theories on the patient-physician relationship have evolved within the last decades to portray a nuanced picture of the traditional patient-physician "dyad". Shifts in social, economic, and technological contexts in which the physician-patient encounters are taking place raised the need for more complex frameworks to study patient-physician encounters. One example of a change to this dyad is the increasing use of second opinions. The second opinion is a ratification tool that critically influences diagnosis, treatment, and prognosis. There are scarce data on the patient-physician relationship in second opinions, specifically from the physician's perspective. We studied the physicians' attitudes toward second opinion encounters. We interviewed 35 orthopedic surgeons and neurologists in Israel, and performed a qualitative analysis of the data using the Grounded Theory approach. The findings exemplify how physicians struggle between their perceived professional image and their vulnerability, as they are sometimes disappointed, offended, embarrassed and resent their patients, and how they strive to preserve their professional authority and autonomy through allegedly 'paternalistic' behavior. The physicians portrayed their patients as striving to conceal the two physicians from each other, creating two dyads that rarely develop into a triad. Along the asymmetry inherent to the patient-physician relationship, we found that physicians and assumedly their patients share symmetric motives and behaviors. We identify two continuums that physicians, and apparently their patients, experience between their different sources of power (whether professional or consumerist), creating a covert conflict over power and control, and between loyalty and autonomy. Finally, we suggested a humanistic approach to understanding physician and patient behavior, based on mutual recognition of needs. Physicians and patients can benefit from communicating openly, positively and respectfully in second opinion encounters. Perceiving the second opinion as a legitimate and empowering tool, that strengthens and widens the patient-physician relationship, instead of weakening it, may result in greater satisfaction on both sides, both for the clinical decision and for a healthy patient-physician relationship.

The surgical management of fibrous dysplasia of bone.

The surgical management of Polyostotic Fibrous Dysplasia (FD) of bone is technically demanding. The most effective methods to manage the associated bone deformity remain unclear. The marked variation in the degree and pattern of bone involvement has made it difficult to acquire data to guide the surgeon's approach to these patients. In light of the paucity of data, but need for guidance, recognized experts in the management of these patients came together at the National Institutes of Health in Bethesda, Maryland as part of an International meeting to address issues related to fibrous dysplasia of bone to discuss and refine their recommendations regarding the surgical indications and preferred methods for the management of these challenging patients. The specific challenges, recommended approaches, and "lessons learned" are presented in hopes that surgeons faced with typical deformities can be guided in the surgical reconstruction of both children and adults with FD.