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Meet the editor of... The Electronic Library
An interview with: David Raitt
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In this interview
Journal direction and coverage
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Dr David Raitt, FCILIP, FRAS is Senior Technology Transfer Officer with the European Space Agency in The Netherlands. He has worked with ESA since 1969, as an information scientist responsible for introducing online interactive information systems throughout Europe, as a librarian and as an advisor on internet strategy. Currently his activities involve:
identifying and researching new breakthrough technological opportunities to ascertain their subsequent spin-off/spin-in possibilities in new markets
facilitating and fostering synergies and contacts between potential users of space technologies
making the general public more aware of space technologies and concepts and the benefits that can result from technology spin-off
conducting and managing studies on advanced space technology concepts to ascertain their technology transfer and promotion potential in the most important socio-economic sectors
championing the case for art and culture relating to space
helping to develop scenarios and strategies for sustaining human life in space.
He has also been active in the area of digital librarianship and is currently co-Chair of the Internet Librarian International conference held annually in London. He was also Chairman of the International Online Information meetings for some 18 years, and formerly Chairman of the annual conference on World Wide Web Applications held in South Africa. He founded The Electronic Library in 1983 to cover the applications of technology in information environments.
The Electronic Library aims to be a comprehensive source of information on all aspects of the digital library all over the globe. It covers the applications and implications of new information technology, including automation, user interfaces, networks and the Web in library and information centres, and aims to report research results, describe and recommend applications, and provide news and reviews.
Dr Raitt talked to Catherine Ebenezer, Information Systems Manager at the Royal College of Midwives. Catherine holds an MSc in Information Science (computerized library systems), and her professional interests include website design, web usability, electronic journals, library system technologies, and clinician information use. She has written for Emerald journals and reviews articles from The Electronic Library for the journal eLucidate.
Why did you found The Electronic Library?
At that time, in 1983, I was the chair of the International Online Information Meeting, and I also and wrote columns for Online Review and Electronic Publishing Review on new technology. These professional activities provided the impetus to setting up the journal as I felt that there was a niche for a publication which dealt with issues on information technology and library automation.
It also helped that both the journals and the conference belonged to the publisher Learned Information, so there was a ready-made "home". In February 2000, The Electronic Library (TEL) was bought by Emerald which had already acquired a number of librarianship journals, and therefore saw TEL as a relevant addition to its portfolio.
From your viewpoint as editor of TEL, how would you briefly characterize the main trends and developments in library technologies since then?
When I first set up the journal, and in the years afterwards, I pushed very strongly for IT developments in libraries. From my vantage point working for ESA, I was aware of technological developments both in practice and also in the literature. This was before the consumer ICT boom, but there were devices mainly aimed at business executives: hand held computers, electronic books with information stored on a credit card, and eyeball sized small screens which would project a computer screen apparently at normal size. I was interested in how such developments could be used in libraries and took pains to explain this to my audience. However, I was way ahead of my time – they didn't catch on and then they were soon left behind by developments concerning the Internet, but now, particularly with the quantum leap in consumer IT products such high-tech devices are making a comeback and making people far more used to this sort of thing in libraries.
Nowadays, library technology is much more likely to be web rather than mainframe based, with less interest in automation issues. However, that's not so true developing economies, such as in Africa and Asia.
Would you describe The Electronic Library as written by practitioners for a practitioner audience? Or does it have a readership in Library and Information Studies Departments?
It's a practical tool for librarians. The idea is that if libraries know what each other is doing, then that helps to improve their systems and procedures. It's written by practitioners for practitioners, but it does have a readership in library and information studies, students use it for case studies, and it is much cited in doctoral dissertations.
What are the main issues in researching and publishing in such a fast-moving, multidisciplinary field?
Dating back to the journal's early days when there were very few papers, I've always been a very proactive editor. I come across articles in journals, at conferences, or I meet potential contributors at meetings, and contact people to persuade them to write for the journal. However, TEL benefits now from being part of the Emerald machine, with its network of journals and researchers, so the journal is better known and we get a lot more unsolicited papers, and particularly from parts of the developing world.
I try and broaden the experience of readers by accepting articles which tell them things that I think perhaps they might like to know about because they could be useful in their work and which they might otherwise not readily come across – an example might be security issues surrounding computer gaming. TEL is a scholarly journal, not a glossy news magazine, so the articles are fairly timeless and not subject to obsolescence as they would be if they were just concerned with reporting news and the latest trends and developments. We can be flooded with papers for our six issues a year, so sometimes the delay between acceptance and publication is longer than we would wish. I try and get a balance for each issue with different types of articles from different parts of the world.
What differentiates TEL from its competitors? Does it have a particular market "niche"?
There are two main competitors – both of which are also published by Emerald – the American Library Hi Tech, and Program, which is smaller but which takes up much of the UK market. In addition, there are several journals in the digital librarianship field, many of which are web-based.
The "niche" occupied by TEL is its global scope in coverage and readership: it is read in, and receives papers from, just about every country in the world. That gives it a very wide perspective on developments in library information technology.
The difficulty here is getting people to be interested in developments in the less developed world, when the rest of the world has moved on. Some countries, like Taiwan or China or Malaysia, are relatively advanced technologically speaking, but the African and Indian countries are catching up with initiatives such as OPAC, the World Wide Web, CD-ROM, etc. However, I see it as important to give people a chance to describe where they are currently – for them, writing up such developments and programmes is just as important as they were for us in Europe or the USA some 10, 15, 20 years ago. The UK and USA led the world then in say OPAC and CD-ROM research and while they have long dropped off the horizon as new technologies in libraries – they are just starting to be used in some developing economies, who can justly be proud of their advancement and who want to tell other countries in the same situation what they are achieving. For those people, TEL is a good medium to learn from.
That's another reason for balancing issues – we need to mix the technologically advanced with the less technologically advanced, so when I get several papers from emerging economies I will balance these with articles about the web, going after top notch authors. Ideally, I like each issue to contain something for everyone – I see it as the National Geographic magazine of the library and information world!
How do you envisage the journal developing over the next few years?
More of the same, with the balance going towards the hi tech articles. A number of trends – the advent of consumer technologies and the price for these coming down, the growth of mobile and wireless technologies, and the increasing use of solar power – all these mean that internet technologies spread wider and wider including into rural areas worldwide. These trends will spill over into the library world, and will mean that the time of catching up for emerging countries will be much shorter.
The articles in TEL are classified as research reports, case studies, technical papers, and literature reviews. What balance are you looking for between different types of article, within an individual issue and in your overall coverage? Are there any types of submission that you are seeking more of?
I'm not looking for any particular balance or editorial mix of article types. I like practical papers. Many people submit research type papers which have a very heavy review of the literature component – but I'm not too keen on these on their own as they tend to be mainly a rehash of the author's degree thesis and the references are woefully out of date and over-quoted. I really don't care or need to know, for instance, that Joe Bloggs opined in 1986 that computers could be used for journal circulation. The sad thing is that in some parts of the world, the resource base may be out of date if the library is poorly stocked and access to the Internet is limited because of the state of the telecommunications infrastructure in the country.
What would be your dream article?
One that was in perfect English and laid out very well! I like papers that are interesting to a wide readership, and that grab the reader's attention. It can be something to do with the Web, or a description of setting up a butterfly museum in Taiwan; we recently did a special issue on computer games (these are now often part of a library's collection just as are books and music), and we published articles on issues which librarians should be aware of, such as the problems of stealing code. I like to get people to read up on issues which are in different areas from their normal interests.
What are your main criteria for assessing research articles?
Articles should be between 3,000-6,000 words, and at that length you are not going to be able to say all that much about the research methodology. Thus the article must stand alone and be sufficient to make the reader understand what the author did without being too long and detailed – in essence it's like a good executive summary.
The regular reader cannot fail to be struck by the international scope of the journal, particularly its focus on information services in developing countries. How do you ensure that this is maintained? What particular value do you think this has for your readership within the developed world?
It was not a deliberate policy to make TEL a developing-world journal, but it has evolved a bit that way through the international nature of Emerald, which has got many subscribers in developing countries. We have contributions not just from academic libraries but also from, say, military academies, research associations, government offices, national libraries – and discussing all types of topics – use of the Web for digitizing and disseminating data from weather stations, use of IT by petroleum companies, introduction of cybercafés, websites being used by native American librarians and so on. Several members of the Editorial Advisory Board are from the developing world – they may have contributed a couple of articles to TEL, and I then invite them to join the Board and also request them to look around for other contributors in their region.
I feel that the journal provides a great opportunity for authors in developing economies, in that if someone has something to say, they will have as much chance to say it as if they were contributing from the USA, UK or Europe. Thus it provides them with an outlet or voice for getting their views and progress into the wider world, better than other local journals. It also provides them with useful stature when it comes to tenure and promotion – just as it does with authors from the USA.
How are decisions made concerning the topics for themed issues?
Sometimes they come as a result of a conference, as with the computer games issues, which was a way of bringing to the attention of librarians the security and networking matters which they needed to be aware of. A couple came from a library conference in New Zealand, including a special issue on the impact of information technology on indigenous people. Sometimes, they are suggested by receiving a large number of papers e.g. we got a lot of papers from Nigerian contributors so we decided to have a special issue on Nigeria. On another occasion, I had two or three unsolicited papers on e-books so I persuaded others I knew to write additional papers in order to create a special issue on that topic.
The decisions as to special issue topics are always the editor's. The downside, if you can call it that, is that it means extra papers, and therefore increases the wait for the other articles already in the pipeline.
"Making Botswana an information society: current developments" by Stephen M. Mutula (Vol. 22 No. 2) won an Outstanding Paper Award. What was it that made this paper exceptional?
Every year I select a number of papers from the year's issues and send them to the Editorial Advisory Board for comment. I also invite them to make their own recommendations. Mutula's paper was a very good and detailed paper, well researched, well-written and well worth reading as a serious contribution to the literature.
What happens to papers once they hit your desk? Are they peer reviewed? How long does it take for an article to be published?
All articles now come via e-mail, and I print them out and take them home to read. The journal is peer reviewed – every article goes to one or two reviewers, and I also review every article myself. The only time when I won't get an article peer reviewed is if I'm either very familiar with the topic or if I trust the source. The peer review process is generally trusted by authors as a quality indicator – they prove to the interested subscriber that the article has been looked at – and accepted – by others who have a certain professional standing and are familiar with the subject being discussed.
The peer review process happens fairly quickly; reviewers know I like their comments back within a week or so and they also know that I will chase them if necessary. Authors usually send their revisions back quickly.
I do have a bit of a backlog of accepted articles, so I try and make sure that the earlier papers get published first. However, I have to consider the balance of the issue: I may want to include a brand new paper right away if the topic is right or to have a perspective from say a more technologically advanced country.
So, the time to publication can vary from 3-12 months from acceptance.
What is the best means of ensuring successful electronic dissemination of articles?
Emerald's structured abstracts help here, but it's also important to have keywords and make the title short and punchy. I add keywords myself if I think they would improve retrievability of the article and I also sometimes modify a longer (thesis-type!) title.
Dr David Raitt was interviewed in October 2005.


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Home Books Rudolph's Pediatrics, 22e
Chapter 213. Disorders of the Foot
Charles E. Johnston
Johnston CE. Johnston C.E. Johnston, Charles E.Chapter 213. Disorders of the Foot. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA. Rudolph C.D., & Rudolph A.M., & Lister G.E., & First L.R., & Gershon A.A.(Eds.),Eds. Colin D. Rudolph, et al.eds. Rudolph's Pediatrics, 22e. McGraw Hill; 2011. Accessed January 28, 2023. https://accesspediatrics.mhmedical.com/content.aspx?bookid=455&sectionid=40310501
Johnston CE. Johnston C.E. Johnston, Charles E. (2011). Chapter 213. disorders of the foot. Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA. Rudolph C.D., & Rudolph A.M., & Lister G.E., & First L.R., & Gershon A.A.(Eds.),Eds. Colin D. Rudolph, et al. Rudolph's Pediatrics, 22e. McGraw Hill. https://accesspediatrics.mhmedical.com/content.aspx?bookid=455&sectionid=40310501
Johnston CE. Johnston C.E. Johnston, Charles E. "Chapter 213. Disorders of the Foot." Rudolph's Pediatrics, 22e Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA. Rudolph C.D., & Rudolph A.M., & Lister G.E., & First L.R., & Gershon A.A.(Eds.),Eds. Colin D. Rudolph, et al. McGraw Hill, 2011, https://accesspediatrics.mhmedical.com/content.aspx?bookid=455&sectionid=40310501.
Disorders of the Foot: Introduction
A common referral to a pediatric orthopedist is for a foot deformity that may or may not be symptomatic. Conditions range from benign, self-resolving, perceived abnormalities involving the forefoot and toes, to more severe congenital and neuropathic deformities including clubfoot, congenital vertical talus, and cavus foot. Frequently, differentiation between a benign, resolving condition and a more severe pathologic deformity can be made by clinical examination and level of suspicion. A review of the common disorders, both benign and pathologic, will be presented to assist in the office evaluation of pediatric foot conditions.
Metatarsus Adductus
Medial deviation of the forefoot of an infant, termed metatarsus adductus, is one of the most common pediatric foot conditions (Fig. 213-1). Intrauterine positioning—medial rotation of the foot across the fetal torso—is the presumed cause of this positional deformity. The "deformity" is usually flexible and can be passively corrected, in which case no treatment is actually necessary. Rare cases with severe rigid deformity may require treatment.1
Figure 213-1.
A: Dorsal view of bilateral metatarsus adductus. Note the medial deviation of all toes. (Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring, Fig. 23-19A.)B: Plantar view. The lateral border of the foot is curved and "bean shaped." (Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring, Fig. 23-19B.)
Clinically, the forefoot is medially deviated in relation to the hindfoot. When viewed from the plantar surface, the lateral border of the foot is curved and appears "bean shaped" (Fig. 213-1B). There may be additional medial deviation of the great toe and the appearance of a high arch.2 The deformity can be passively "corrected" if the examiner grasps the heel and maintains it in the neutral position, while abducting the forefoot (eFig. 213.1). Metatarsus adductus is almost always bilateral, although some children will demonstrate a "windswept" position of the feet, with one foot internally rotated with metatarsus adductus, and the opposite externally rotated by the intrauterine position.
eFigure 213.1.
Passive correction by abducting the forefoot while maintaining hindfoot position with counterpressure on the lateral aspect of the heel. (Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring, Fig. 23-19B.)
Many children will present at walking age with intoeing. Metatarsus adductus is but one reason the foot progression angle can be deviated medially—the most common being internal tibial torsion (ITT). By observing the plantar surface of the foot (Fig. 213-1), the contribution to the intoeing coming from the forefoot can easily be appreciated and differentiated from ITT. Metatarsus adductus is distinguished from talipes equinovarus (clubfoot) by noting that the ankle and hindfoot have a normal range of dorsiflexion and plantarflexion, whereas a true clubfoot has a fixed hindfoot deformity (see discussion below). Rarely, the forefoot may be medially deviated in a foot that appears to have severe midfoot and hindfoot valgus, a foot that is commonly described as skewfoot (see discussion below).
Treatment of metatarsus adductus varies from observation to casting in more severe presentations.2,3 If the forefoot can be passively manipulated into a corrected position, then the parents can be instructed in passive stretching, and the "deformity" can be observed. Full resolution can be expected. Night splints or reverse-last shoes for children younger than 6 months can also be utilized, although there is little evidence that such orthotic treatment facilitates what would otherwise be spontaneous resolution. If the forefoot is not passively correctable, a short period of casting may be warranted. If using short leg casts, one must carefully insure that the heel is not pushed into valgus during the maneuver to abduct the forefoot and straighten the lateral border (eFig. 213.1).
Surgical correction is reserved for the rare patient with a fixed adductus, and symptoms. The decision for operative treatment, whether soft tissue release or bony procedures, is controversial. Orthopedic consensus is that, even with moderate fixed residual adductus, adult function is still normal.2,3
Calcaneovalgus Foot
This postural deformity of infancy is characterized by a sometimes dramatic hyperdorsiflexion position, where the dorsum of the foot is plastered to the anterior surface of the tibia (Fig. 213-2). Plantarflexion is limited, and the condition may seem severe if the contractures of the dorsal ankle structures do not allow early manipulative relief (eFig. 213.2).
Hyperdorsiflexed position of a calcaneovalgus foot.
A, B: Manipulation of a calcaneovalgus foot into plantar flexion, stretching the contracted anterior ankle structures. Note the upward movement of the heel as the forefoot is plantarflexed. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-24A,B).
The foot may also be deviated laterally, the "valgus" portion of the deformity, preventing inversion of the foot. The key is to determine whether the heel is also in dorsiflexion. If the heel has descended and moves appropriately upward when the forefoot is plantarflexed, one may conclude that this is a postural, in utero deformity, resulting as a "packaging" defect, which will resolve with time and manipulative stretching.4,5 On the other hand, if the heel has not descended with the hyperdorsiflexed forefoot or does not move appropriately when the forefoot is raised and lowered, then a congenital vertical talus must be ruled out. The latter is usually characterized by the foot having a "rocker bottom" appearance, due to the fixed equinus of the heel (see discussion below). Hip dysplasia must be ruled out in the newborn with a hyperdorsiflexed foot, because the same abnormal in utero fetal position responsible for the calcaneovalgus foot can also cause hip dysplasia.5 A less subtle deformity is a posteromedial bow of the tibia that may present concomitantly with the calcaneovalgus foot. In the latter, the tibia is deformed with an apex based posteriorly, which is easily understood as an additional packaging defect associated with the hyperdorsiflexed foot.6 However, the posteromedial bow of the tibia will require some orthopedic intervention due to the shortening of this portion of the lower extremity.
Once congenital vertical talus, posteromedial bow of the tibia, and hip dysplasia have been ruled out, then The hyperdorsiflexed foot can be treated by gentle manipulation and stretching, pushing the foot into plantarflexion (eFig. 213.2). Such stretching exercises can be taught to the parents. Inversion of the foot may also be carried out as a corrective maneuver. Typical calcaneovalgus foot will resolve spontaneously in a period of 3 to 6 months, although occasionally a more severe case may be referred to the orthopedist for either splinting or casting. Parents should be educated as to the benign nature of this deformity, but they should also be warned that there may be a flatfoot appearance when ambulation begins.
Flexible Flatfoot (Pes Planovalgus)
Flatfoot is probably the most common "deformity" evaluated by pediatric orthopedists. Whether it constitutes an actual deformity is, in fact, questionable.7 In general, the weight of the child's body in the presence of lax ligaments in the foot flattens the normal arch. In the infant and pretoddler child, a "fat" foot should not be mistaken for a flatfoot, as the arches of infants and young children are often obscured by subcutaneous fat.8 Finally, a lower arch is a normal variant. It is thus surprising that flatfoot is evaluated and treated, often prophylactically by nonorthopedic branches of medicine, fearing that the loss of the longitudinal arch, however subjective, will result in symptomatic disability.
There is no universally accepted definition of flatfoot. The normal height of the longitudinal arch is unknown, and radiographic analysis of the foot is rarely indicated if the physical examination does not reveal a specific indication (see discussion below). The appearance of a flatfoot is well known—the heel is everted with a loss of height, and the talar head and navicular appear to rest on the floor medially. The medial column of the foot may appear longer than the lateral column. When viewed from behind, the examiner may note that all five toes are visible to the lateral side of the tibia (called "too many toes" sign) (eFig. 213.3). However, while observing the child from behind, the examiner may request that the child go up on tiptoes, at which time in the flexible flatfoot, the longitudinal arch will reconstitute, and the heels will invert (eFig. 213.3C). This simple maneuver basically rules out any significant congenital foot pathology. When examining the foot with the child seated and the foot dangling, the flexible flatfoot will demonstrate ease of inversion and eversion, and again the longitudinal arch will be seen to reconstitute.
A, B: Front and back views of flatfeet, showing weight bearing on the medial column of the everted foot, and "too many toes" visible when viewed from behind. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-28A,B). C: On tiptoes, the heel inverts and the arch is reconstituted. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-28C).
The differential diagnosis of flatfoot includes conditions such as congenital vertical talus, in which the heel is in equinus and will not correct, and tarsal coalition, in which there is marked restriction of subtalar and midfoot movement, most easily detected by the tiptoes test just described. Tarsal coalition usually presents in older children, typically because of pain.
A decreased longitudinal arch has been described in as much as a quarter of the adult population, and thus must be considered a normal variant. This, however, does not remove the possibility that the patient may have symptoms, which are almost always associated with a contracture of the triceps surae9 and can be detected by dorsiflexion of the foot with the heel stabilized in neutral and the knee fully extended. Patients with a tight triceps complex tend to have more complaints from their flexible flatfeet. Should heelcord contracture be suspected, the child should be asked to walk on his or her heels, which will be difficult with a significant contracture.
Treatment of flexible pes planovalgus depends on the presence or absence of symptoms. Asymptomatic flatfeet require no treatment, with education and reassurance being given to the parents. There is no evidence that prophylactic treatment of flexible pes planovalgus prevents either the development of symptoms or the progression of a deformity.10,11
In symptomatic patients, a variety of shoe inserts, shoe modifications, and exercises are available. If the child has a tight heel cord, then exercises to stretch the gastrocsoleus complex are indicated (eFig. 213.4). The most effective exercise is the gentle dorsiflexion of the foot with the heel stabilized in neutral and the knee in full extension. Calf muscle stretching by leaning forward with the feet inverted, knees extended, and hands on a wall is also recommended (eFig. 213.4). For heel eversion, a medial heel wedge attached to the sole of a shoe may be useful, and with more symptomatic feet, the use of a soft or rigid insert to invert the heel and support the longitudinal arch are often considered (eFig. 213.5). There is no evidence, however, that any of these corrective devices change the anatomic structure of the foot. In light of the not-insubstantial costs of some of the custom-molded orthotics, there is little justification for prescribing such devices unless symptoms warrant. Perhaps the most effective shoe modification for the child with painful flexible pes planovalgus is the recommendation to purchase "running shoes" from an athletic store. Such running shoes, often prescribed for "hyperpronated feet," include most of the modifications, such as a medial heel wedge, arch support, and rigid heel cup, which are normally prescribed by physicians and gladly provided by orthotists. The use of such running shoes makes prescription of these additional orthoses unnecessary.
A: Stretching the heel cord by dorsiflexing the inverted foot with the knee fully extended. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-29A).B: Stretching the triceps surae (older child). Note the feet are inverted, the knees extended, and the heels remain on the floor. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-29B).
A: A rigid University of California Biomechanics Laboratory (UCBL) insert with medial arch "support." Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-30B). B: Plastazote molded arch support with medial "wedge." Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-31A).
There are occasionally older adolescents whose hypermobile flatfoot continues with intractable symptoms in spite of stretching exercises and shoe and orthotic prescriptions. Such patients are rare and represent the only true candidates for surgical management. Because many of the surgical procedures for hypermobile flatfoot are often unsatisfactory in long-term outcomes, pediatric orthopedists are reluctant to recommend such treatment except in the most dire of circumstances. In order to change the anatomic position of a hypermobile flatfoot, some form of stiffening of the joints of the foot—either by imbrication, osteotomy, or fusion—must be applied to the foot. Although short-term efficacy is to be expected, longer-term studies report unsatisfactory results from such surgery,12-14 because all of these stiffening maneuvers will result eventually in osteoarthritic changes within the foot at the adjacent unfused joints. For this reason, only the most recalcitrant of hypermobile flatfoot is ever considered for surgical correction.
Skewfoot
This rare deformity resembles metatarsus adductus but also has the elements of hindfoot valgus and is usually more rigid and severe than any metatarsus adductus alone (eFig. 213.6). Skewfoot has also been termed serpentine or Z-foot, based on the radiographic deformity (eFig. 213.6). Patients will usually present because of discomfort under the base of the fifth metatarsal or under the head of the talus on the medial side. The rigidity of the skewfoot is the striking difference between its relatives, simple metatarsus adductus or simple hypermobile flatfoot.
Radiograph of a serpentine "z" foot. There is a zig-zag deformity between the everted heel, the abducted midfoot, and the adducted forefoot. In addition, the forefoot is supinated (first metatarsal is dorsally displaced compared to the fifth). Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-38C,D).
Patients usually present in older childhood or adolescence when pain and complaints become more severe.15 Because of the later presentation and rigidity, nonoperative methods are rarely successful. Operative treatment may be indicated if symptoms warrant and is often complex due to the rigid deformities at multiple points from the heel to the forefoot.
Clubfoot (Talipes Equinovarus)
Clubfoot is probably the best-known pediatric foot condition requiring treatment, having been known since ancient times. It represents congenital dysplasia of all musculoskeletal tissues distal to the knee and is present in 1 to 2 per 1000 live births. Ancient practitioners struggled with producing an acceptable outcome for clubfoot just as modern orthopedists do because of the myriad of pathologic findings that prevent an optimal outcome from being achieved. Regardless of whether a clubfoot is corrected nonoperatively or operatively, there always appears to be some degree of impairment in the function of the extremity, due to restricted motion in the ankle and hindfoot, diminished muscle strength and power generation of the triceps surae, and kinetic and kinematic abnormalities related to atrophy and fibrosisof the musculoskeletal tissues below the knee. Clubfoot is a congenital abnormality that begins developing prior to the 12th week of gestation; thus, by the time the infant is born, the congenital dysplasia of the lower limb has been present for up to 7 months of intrauterine life.16,17
Evidence of such dysplasia is noted when one looks, for example, at the severely dysmorphic bones of the fetal clubfoot (eFig. 213.7). This difference, combined with the soft tissue fibrosis that impairs manipulative correction, defines why clubfoot is a serious congenital anomaly. Modern treatment, which has returned to an emphasis on nonoperative methods, seeks early anatomic correction while at the same time providing as much motion as possible to counteract atrophy and muscle weakness. Clinical identification of the clubfoot is rarely difficult. The classic appearance of the heel in marked equinus with the foot severely inverted on the end of the tibia is unmistakable (Fig. 213-3). The foot may approach a position of being upside down in relation to the normal position. Lack of correctability of the inversion and the heel equinus separates the true clubfoot from a more mild postural deformity. At the time a newborn infant with a clubfoot is evaluated, Other associated syndromes or conditions, such as Down syndrome, arthrogryposis (eFig. 213.8), skeletal dysplasias, spina bifida or spinal dysraphism, or other trisomy and dysmorphic conditions should be kept in mind. Although concomitant dysplasia is reported to occur in less than 1% of patients with idiopathic clubfeet, a screening hip examination should always be done.
A: Thin section of a normal fetal foot. T, talus; N, navicular. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-40A).B: Corresponding section of a clubfoot. The navicular articulates with the medial neck of the talus, which is strikingly dysmorphic (hypoplastic body, neck, and pointed deformed talar head). Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-40B).C: Normal and clubfoot Calcaneo-cuboid joint. The same dysmorphic features and medial subluxation as seen in the talonavicular joint are present (modified from Carroll, NC, etc.). Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-40C).
A: Dorsal view of untreated clubfoot, showing equinus, cavus, heel, and forefoot varus. B: Posterior view. Due to severe inversion/varus, the patient bears weight on the dorsum of the lateral side of the foot.
(Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring.)
The most severe clubfeet in a neonate with arthrogryposis.
The infant with a clubfoot should be referred quickly, as it is generally agreed that the earlier treatment is begun, the more likely that nonoperative methods will be successful. This is due to the relatively viscoelastic character of the newborn foot, which rapidly becomes nonelastic if treatment is delayed beyond the age of 3 months. Nonoperative treatment has become the mainstay because of the clearly unsatisfactory long-term results obtained with surgery, based on many studies demonstrating that surgically treated feet are stiffer and weaker, due to scarring and muscle atrophy.18,19 Nonoperative treatment proposes to gradually correct the clubfoot deformity without producing the scar tissue that inevitably diminishes the result.
Two methods of nonoperative treatment are currently employed. The first is serial casting, described and popularized by Ponseti of the University of Iowa.20 This method, which involves weekly manipulation and cast application, proposes to correct the foot and allow relaxation of the collagen and remodeling of the osseous structures without producing fibrosis and scarring. The technique is usually spread out over 4 or 5 cast applications done weekly (Fig. 213-4), with a percutaneous heel-cord release done prior to the final cast to bring the foot out of equinus, commonly the most recalcitrant of the four major deformities (cavus, adductus, varus, equinus) that characterize a clubfoot. The retention of the corrected position by a long-leg cast is an important aspect of the Ponseti method, as is the percutaneous heel-cord prior to the final casting Over the 5 weeks of casting, the foot is gradually brought out of cavus and externally rotated, with the dorsiflexion of the foot being the final maneuver assisted by the percutaneous TAL (tendoachilles lengthening). A certain degree of "overcorrection" is sought by the final cast so as to ensure full derotation and correction of the initial cavus, adduction, and varus (Fig. 213-4). Following removal of the last cast, an equally important period begins of bracing the foot in the corrected position by the use of a Denis Browne bar attached to shoes which maintains the feet in 50 to 70 degrees of external rotation (eFig. 213.9). The orthosis is worn full time for a period of 4 months, and then part time for up to 2 years to maintain the correction.
Progression of clubfoot correction with serial casting. The final cast is applied after percutaneous heel-cord lengthening to bring the foot out of equinus. (Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring.)
The Denis Browne/Ponseti brace. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-47).
The results of the Ponseti technique have generally been favorable, with 90% of patients undergoing early treatment avoiding surgery20 (the percutaneous TAL is not considered a surgical procedure as it is part of the initial protocol). The avoidance of early surgical procedures is one of the great advantages of the Ponseti method, and long-term outcomes document that by physical examination over half the feet are considered "normal," although there are both motion and radiographic changes that characterize the residual of any clubfoot. It must be realized, however, that relapses of corrected clubfeet with the Ponseti method are relatively common, requiring additional casting, limited surgical releases, or tendon transfers in order to obtain correction over the longer term. Most studies, however, report a high degree of success with Ponseti's method despite recurrences reported for up to one third of the patients.
The second nonoperative method is termed the functional or French method, having been developed in Europe, primarily by French orthopedists, in the 1980s.21 The method is considered functional because the foot is stretched daily by trained physiotherapists, with the correction being maintained overnight by a method of taping. The passive manipulations are combined with active stimulation of dorsiflexors and peroneal muscles for a period of 2 to 6 months. Nighttime splinting for up to 2 to 3 years follows.
The French method became known in the United States in the 1990s. Its primary deficiency is the fact that trained physical therapists are necessary for it to succeed, and it is considerably more time consuming than the weekly castings of the Ponseti method. Cooperation and transportation of families is essential for such a program to work, and obviously, patients who live a long distance from the treatment center cannot participate successfully. Nevertheless, in patients able to undergo the French method, similar results have been obtained in the short term, with surgical releases generally being avoided in the first year of life.21 Posterior release, however, is frequently required, because the equinus deformity is not addressed surgically until the child begins ambulation.22 Residual equinus, the most resistant of the clubfoot components, may not be adequately corrected except by percutaneous TAL or posterior release, frequently delayed until ambulatory age.
Surgical correction is appropriate for a foot that is resistant to nonoperative methods. Although many orthopedists believe that surgery is the only method to completely correct a severe clubfoot, the long-term outcome of the surgically treated feet, critically reviewed in the 1990s by several investigators,18,19 demonstrates that multiple operations are common but need to be avoided, and that recurrence is almost always due to incomplete correction. The stiffness and atrophy as well as scarring from operative procedures leave no doubt that surgery for clubfoot should not be the primary choice.
Typically surgery is performed around walking age in the patient who has failed nonoperative methods early due to intolerance of casting, intolerance of posttreatment bracing (DB bar), or noncompliance with either of the nonoperative protocols. There is no advantage to performing surgery earlier than walking age, because the ability to be fully weight-bearing in the postoperative period may in fact be of great assistance in maintaining correction by encouraging a plantigrade foot with no equinus. Soft tissue releases are recommended as the first approach at this age and include extensive ligament and tendon releases and lengthenings, from the posterolateral corner of the ankle and subtalar joint to the medial side of the midfoot. The extent of the procedure must be evaluated intraoperatively in order to ensure that both under- and overcorrection are avoided. As mentioned earlier, although undercorrection is most frequently the cause of "relapse" and leads to repeated surgical procedures, overcorrection into excessive valgus and dorsiflexion can also occur, with debilitating long-term functional implications. The surgeon who is the first to operate on a congenital clubfoot bears a great responsibility in that subsequent operative procedures will almost certainly be regarded as salvage, and whatever improvement in anatomic position that is achieved will almost undoubtedly be accompanied by functional disability due to weakness and stiffness.18,19
Congenital clubfoot remains a treatable but somewhat unsolved problem in pediatric orthopedics. The outcome of treatment depends significantly on the severity of the deformity at presentation, as well as the timeliness and competence of the nonoperative treatment. Competence and timeliness notwithstanding, success also depends significantly on the compliance of the family in maintaining the corrected foot in an appropriate orthosis until walking age, with timely limited surgery being appropriate if there is residual deformity or recurrence following the initial nonoperative method of infancy.
Congenital Vertical Talus
Congenital vertical talus (CVT), also known as congenital convex pes valgus, is a rare foot anomaly, typically differentiated from clubfoot by the appearance of the foot resembling a rocker-bottom deformity (Fig. 213-5). The pathology in CVT is a teratologic dorsal dislocation of the talonavicular joint, in which the midfoot and subtalar joints are dislocated dorsally and laterally while the heel is still fixed in equinus (Fig. 213-5B). In a sense, the reverse of the inverted cavus deformity represents clubfoot.
A: Congenital vertical talus with "rocker-bottom" appearance. B: Dorsal dislocation of talonavicular joint combined with heel equinus.
CVT often presents in association with arthrogryposis or myelomeningocele and various trisomy syndromes. In fact, idiopathic vertical talus is a relatively rare entity, so the patient presenting with a true convex pes valgus must be evaluated for a generalized condition or syndrome.
Clinically the foot has a rocker-bottom appearance, due to the heel being in equinus, combined with the talar head presenting itself in the medial plantar sole of the foot (Fig. 213-5). The forefoot is everted and dorsiflexed and cannot be inverted, due to the contracture of the soft tissues of the dorsum and lateral aspect of the ankle. The navicular is palpable on the dorsum of the talar neck.
A lesser degree of severity may manifest itself as an oblique talus. In this situation, the dorsilateral structures of the ankle are not as severely contracted, and the navicular can be reduced onto the head of talus when the forefoot is plantarflexed and inverted. The heel remains in some degree of equinus.23 This feature—the residual equinus of the calcaneus—and the resulting plantarflexion of the talus describe the radiographic appearance on the lateral X-ray which gives the condition its name—the talus is vertical and parallel to the longitudinal axis of the tibia (eFig. 213.10). Any foot of a newborn or young child which has heel equinus, a rocker-bottom appearance, and lack of inversion and plantarflexion should be suspected of having CVT.
eFigure 213.10.
Lateral radiograph of a congenital vertical talus. The calcaneus is in equinus (plantar flexion) and the talus appears to be vertical, parallel to the long axis of the tibia and fibula. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-74A).
Differential diagnosis for CVT includes a calcaneo-valgus foot. The latter deformity is not easily confused when the heel is seen to descend appropriately when the foot is dorsiflexed. At walking age, a severe flatfoot with a heel-cord contracture may also be mistaken for a vertical talus. This is differentiated by the fact that flatfoot can be inverted and plantarflexed, with the navicular reducing on the head of the talus, and whatever valgus is seen in the flatfoot can also be corrected by inversion. No such flexibility occurs with CVT. Obviously, if any doubt remains following clinical evaluation, a lateral radiograph of the foot in plantarflexion will settle the issue (eFig. 213.10).
Treatment of the congenital vertical talus includes early casting in an attempt to stretch the contracted dorsilateral structures and reduce the navicular on the talus, followed by operative open reduction of the talonavicular joint and release of the hindfoot equinus. The procedure is similar in many ways to the clubfoot release and can be done at any age from immediately prewalker to mid-childhood, depending on the time of recognition of the deformity. The results tend to be better in children under the age of 2, and older children usually require some form of joint stabilization by arthrodesis in order to prevent recurrence.24 Long-term functional outcome of CVT is uncertain, because most patients with CVT have various disabilities and low functional demands due to comorbidities associated with their underlying syndrome or chromosomal abnormality.
Tarsal Coalition
This condition usually presents as a painful flatfoot. By definition, there is an abnormal lack of segmentation between two or more bones of the foot, and this accounts for the rigidity and pain that bring the patient for evaluation.25,26 Because of the rigidity and appearance of the foot, the condition is also known as peroneal spastic flatfoot.
Patients typically present between the ages of 12 and 16 years, although some coalitions have been documented in children as young as 6 years.27 Pain is almost always the initial complaint and is often located in the tarsal sinus, though it may also be present under the medial malleolus and along the arch of the foot. Pain is often activity related, and patients may notice a progressive external rotation and flatfoot, the latter being responsible for the medial arch discomfort.
The predominant physical finding is decreased range of motion at the subtalar joint, best demonstrated by lack of inversion. Patients are often unable to stand on tiptoes without discomfort, and there is a noticeable lack of inversion of the heel when the tiptoe position is requested. This is in contradistinction to the physical findings of a flexible flatfoot. The hindfoot may be in significant valgus as well, and the resistance to passive inversion is often attributed to spasticity of the peroneal tendons—hence, peroneal spastic flatfoot.
The diagnosis should be suspected in any adolescent with painful flatfeet and restricted inversion. Plain radiographs should include anteroposterior (AP), lateral, and oblique views. A calcaneonavicular coalition, the most common tarsal coalition, is usually readily apparent on the oblique x-ray (eFig. 213.11). On the lateral x-ray, secondary changes suggestive of medial facet talocalcaneal coalition (eFig. 213.11B) include talar beaking and the "C" sign, a crescentic bony ridge underneath the talocalcaneal joint. True visualization of a medial facet coalition usually requires a computerized tomography (CT) scan (eFig. 213.11) with the appropriate coronal plane cuts across the subtalar joint (eFig. 213.11C). Coalitions involving other foot joints, including talonavicular, calcaneocuboid, and others, are rare but can usually be recognized on plain radiographs of the feet.
A: The bony bridge connecting the calcaneus and navicular on an oblique radiograph of the foot. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-83A). B: Lateral X-ray of talocalcaneal coalition. Note the "C" sign (arrows) outlining the edge of the medial facet coalition. C: Computerized tomography scan of complete medial facet coalition on right (left normal).
The differential diagnosis of painful rigid flatfeet includes inflammatory processes involving the subtalar joint, as with pauciarticular juvenile arthritis. A difficult clinical problem is the patient with classic symptoms and findings of a tarsal coalition but in whom no coalition can be identified radiographically. Occasionally fibrous coalitions are found, but surgical treatment of such cases frequently is ineffective or the patient develops recurrence.
Treatment of tarsal coalition, documented radiographically or suspected, should be conservative initially, including the use of orthoses, a short period of casting, and injection of the involved subtalar joint with a combination of local anesthetic and steroid. The latter serves both as a diagnostic as well as a therapeutic modality, with some patients receiving long-term relief of the pain for reasons that are not known. but presumably have to do with decreasing the inflammatory response produced either by the abnormal subtalar motion or an intra-articular pain generator. Patients who fail conservative treatment with documented coalitions are then candidates for either resection of the coalition or subtalar midfoot arthrodesis. A calcaneonavicular coalition is easily excised, and the defect created by the excision is filled with subcutaneous fat taken locally from the same lower leg. A medial facet talocalcaneal coalition is more difficult to resect, with subsequent motion more difficult to achieve. If the coalition is not completely removed, the abnormal subtalar motion will continue. Most authors report success resecting calcaneonavicular coalitions, but talocalcaneal coalitions are more unpredictable.28,29 Large coalitions, as well as average size coalitions in obese patients, seem to be most likely to fail. In the latter circumstance, the presence of a large medial facet coalition may best be treated by subtalar fusion rather than an attempt at resection. The best treatment for medial facet coalitions remains controversial.
The cavus foot is defined by an abnormal elevation of the longitudinal arch. The deformity has complex underlying etiologies and consists of both forefoot equinus and varus as well as pronation of the midfoot. The etiology of pes cavus is often neurologic,30,31 with the most common underlying diagnoses being peripheral neuropathies such as Charcot Marie Tooth disease and tethered spinal cord. Other diagnoses include cerebral palsy, poliomyelitis, Friedrich's ataxia, and myelomeningocele. Idiopathic pes cavus exists but must be made as a diagnosis of exclusion.
The clinical features of a cavus foot include plantarflexion of the forefoot with a high arch, with some degree of varus of the hindfoot and pronation of the first metatarsal (eFig. 213.12). The latter deformity produces an inversion and varus of the entire foot by the tripod effect32 (eFig. 213.12), as the plantar surface of the first metatarsal is the first portion of the foot to strike the ground during weight bearing, then producing an inversion of the entire foot and varus of the heel. Patients typically present because of pain under the lateral aspect of the foot due to excessive weight bearing, as well as complaints of frequent lateral ankle sprains due to the forced inversion in association with whatever muscle imbalance or weakness is present from the neuropathic etiology.
Tripod effect. A: The plantar flexed first metatarsal strikes the ground first during weight bearing. B: Supination of the forefoot and heel inversion due to the tripod effect.
The clinical deformity may be fairly mild, if the primary deformity is only a high arch. Inversion of both the forefoot and hindfoot usually produce callosities or pain under the lateral border of the foot due to the abnormal weight bearing in a more advanced case (eFig. 213.13). Secondary changes, again due to the progression of neuropathic changes, include cock-up and clawing deformities of the toes (eFig. 213.14). Determining the underlying etiology of a cavus foot is the first priority because of possible treatment of conditions involving the spinal cord (including tumors) or the underlying neurologic condition. Conservative measures to relieve the abnormal weight bearing and ankle instability include orthoses to balance the weight-bearing surface of the foot or ankle–foot orthoses (AFOs) to stabilize the ankle, and in the case of a muscle weakness etiology, assist with dorsiflexion. Such methods may be quite efficacious but frequently due to progression of the neuropathic condition, the foot deformity progresses to require surgical stabilization.
"Cock-up" deformity of great toe on right secondary to muscle imbalance (substitution of toe extensors for a weak tibialis anterior in a patient with Charcot-Marie-Tooth disease. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-102A,B).
Surgical procedures to correct a cavus deformity are as numerous as there are underlying etiologies producing it. Depending on the etiology and the severity of the neural imbalance, such procedures as plantar fasciotomy, osteotomy of the first metatarsal and calcaneus, or midfoot osteotomy may be required alone or in combination to create a plantigrade foot with a decreased longitudinal arch and removal of hindfoot varus, thus stabilizing the ankle.32,33 In recurrent or more progressive cases, some form of hindfoot and midfoot arthrodesis, with or without first metatarsal osteotomy to dorsiflex the forefoot equinus, is often required. The surgical goal is to provide stable plantigrade feet that do not require bracing unless the patient also has a foot drop due to weakness of the tibialis anterior muscle.
Hallux Valgus (Bunion)
Hallux valgus in a pediatric orthopedic practice is usually seen in adolescent females who are concerned about cosmesis as well as pain. A positive family history is present in up to three quarters of the patients, and the concern becomes more significant as the child enters adolescence. The deformity consists of lateral deviation of the great toe, with the apex at the first metatarsophalangeal joint (Fig. 213-6). The prominence of the head of the first metatarsal is usually responsible for the discomfort, but the lateral deviation with under- or overlapping of the second toe produces the cosmetic concern. Patients with hallux valgus usually have a rather wide forefoot, making narrow "fashionable" shoes difficult if not impossible to don (eFig. 213.15).
Bilateral bunions, more severe on the right, in a 16-year-old female. The increased width of the right forefoot is noted. (Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring, Fig. 23-114A.)
Postoperative appearance following bunion correction on right. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-114D).
Occasionally, there is an underlying condition associated with the hallux valgus, which may be mild cerebral palsy or connective tissue conditions such as Marfan syndrome or Ehlers-Danlos syndrome. There is controversy whether a flexible flatfoot can actually lead to hallux valgus, as well as the likelihood of recurrence of a hallux valgus deformity in the patient with an uncorrected or untreated flatfoot.34,35
Pediatric patients with hallux valgus should initially be strongly encouraged to avoid surgical treatment. Surgical procedures to straighten the deformity are fraught with untoward effects and complications, not the least of which is recurrence if the patient is skeletally immature or has a significant flexible flatfoot.34,35 Because most procedures involve imbrication of the first metatarsal-phalangeal joint to help maintain correction of the deformity, a certain degree of stiffness will be imparted to this joint, which may impact athletic activities such as running, as well as be the precursor for degenerative arthritis. Unfortunately, the latter can occur in the untreated hallux valgus, and thus there is no consensus on the value of prophylactic correction in adolescents.
If the patient is skeletally immature, surgery should be delayed until maturity, as the risk of recurrence is exceptionally high in younger patients.35 Treatments such as night bracing and stretching exercises of the great toe have value, although there is no evidence that this will provide a long-term solution. Toe spacers and other splints can be tried and may have short-term benefit but again eventually will be unsatisfactory. In patients with pes planovalgus, an arch support and other shoe inserts to decrease the valgus pressure on the great toe are appropriate.
Surgical treatment for the mature adolescent is similar to the treatment for the adult, in that a combination of osteotomies, soft tissue releases, and capsular imbrication are usually used (eFig. 213.15). The indications for the various osteotomies, as well as other adjunctive procedures to displace the great toe dorsally or medially, are sources of orthopedic controversy yet to be resolved. In failed hallux valgus surgery, the final common procedure is a metatarsal-phalangeal fusion, often considered an unsatisfactory outcome because it sacrifices the important function of the great toe during running and push-off.
Polydactyly
Extra toes are probably the most common congenital toe deformities noted, with an incidence of almost 2 per 1000 live births. A positive family history is present in one third of the patients, with the fifth toe being the most frequently duplicated (postaxial polydactyly) (eFig. 213.16).36 Duplication of the fifth toe probably accounts for 80% of the cases of polydactyly of the foot. Preaxial (duplication of the great toe) is less common (eFig. 213.16C) and is seen in association with syndromes including trisomy-13, tibial hemimelia, and Down syndrome.
A: Postaxial polydactyly involving a complete extra sixth ray (metatarsal and phalanges). Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-118A,B). B: Rudimentary sixth toe with no function or skeletal attachment to the rest of the foot. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-120). C: Preaxial polydactyly with hallux varus. Excision and realignment of the first toe are indicated due to the deformity. Reprinted with permission from Tachdjian's Pediatric Orthopaedics, 4th Edition, edited by John A. Herring (Fig. 23-123).
Removal of a duplicated fifth toe can be accomplished at essentially any time but is probably best done around walking age. This allows the toes to enlarge to a point where the surgery is technically simple due to ample skin and soft tissue for coverage. An important aspect of this waiting is also to make the risk of anesthesia less severe than it would be if the surgery were done in a newborn. For duplication of the great toe, general guidelines for when surgery should be attempted are more difficult, because the variety of duplications vary from simple to complex, and some consideration for no treatment should be made if the deformity is not significantly bulky and, as in most cases, the function is nondisturbed. In cases, however, where there is deformity associated with the duplication (eFig. 213.16C), surgical treatment is appropriate when the child begins ambulating and shoe wear becomes an issue.
1. Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg. 2003; 11:312-320. [PubMed: 14565753]
2. Kite JH. Congenital metatarsus varus. J Bone Joint Surg Am. 1967;49:388-397. [PubMed: 6018740]
3. Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of treatment. J Bone Joint Surg Am. 1966;48:702-711. [PubMed: 15580738]
4. Giannestras NJ. Recognition and treatment of flatfeet in infancy. Clin Orthop Relat Res. 1970; 70:10-29. [PubMed: 5445715]
5. Wenger D. Calcaneovalgus and metatarsus varus. In: Wenger D, Rang M, eds. The Art and Practice of Children's Orthopaedics. New York: Raven Press; 1993:103.
6. Hofmann A, Wenger DR. Posteromedial bowing of the tibia. Progression of discrepancy in leg lengths. J Bone Joint Surg Am. 1981;63:384-388. [PubMed: 7204436]
7. Staheli LT, Chew DE, Corbett M. The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am. 1987;69:426-428. [PubMed: 3818704]
8. Wenger D. Flatfoot and children's shoes. In: Wenger D, Rang M, eds. The Art and Practice of Children's Orthopaedics. New York: Raven Press; 1993:77.
9. Harris R, Beath T. Hypermobile flatfoot with short Achilles tendon. J Bone Joint Surg Am. 1948;30:116.
10. Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br. 1995;77:254-257. [PubMed: 7706341]
11. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989;71:800-810. [PubMed: 2663868]
12. Crego CH, Jr, Ford LT. An end-result of various operative procedures for correcting flat feet in children. J Bone Joint Surg Am. 1952;34-A:183-195.
13. Scott SM, Janes PC, Stevens PM. Grice subtalar arthrodesis followed to skeletal maturity. J Pediatr Orthop. 1988;8:176-183. [PubMed: 3350952]
14. Southwell RB, Sherman FC. Triple arthrodesis: a long-term study with force plate analysis. Foot Ankle. 1981;2:15-24. [PubMed: 7308909]
15. Peterson HA. Skewfoot (forefoot adduction with heel valgus). J Pediatr Orthop. 1986;6:24-30. [PubMed: 3941175]
16. Bohm M. The embryonic origins of clubfoot. J Bone Joint Surg Am. 1929;11:229.
17. Kawashima T, Uhthoff HK. Development of the foot in prenatal life in relation to idiopathic club foot. J Pediatr Orthop. 1990;10:232-237. [PubMed: 2312708]
18. Karol LA, Concha MC, Johnston CE. Gait analysis and muscle strength in children with surgically treated clubfeet. J Pediatr Orthop. 1997;17:790-795. [PubMed: 9591985]
19. Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. J Am Acad Orthop Surg. 2003;11:392-402. [PubMed: 14686824]
20. Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford: Oxford University Press; 1996.
21. Bensahel H, Guillaume A, Czukonyi Z, Desgrippes Y. Results of physical therapy for idiopathic clubfoot: a long-term follow-up study. J Pediatr Orthop. 1990;10:189-192. [PubMed: 2312698]
22. Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy method. J Pediatr Orthop. 2005; 25:98-102. [PubMed: 15614069]
23. Kumar SJ, Cowell HR, Ramsey PL. Vertical and oblique talus. Instr Course Lect. 1982;31:235-251. [PubMed: 7175175]
24. Stricker SJ, Rosen E. Early one-stage reconstruction of congenital vertical talus. Foot Ankle Int 1997;18:535-543. [PubMed: 9310763]
25. Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop Relat Res. 1983;177:54-60. [PubMed: 6861407]
26. Harris RI. Rigid valgus foot due to talocalcaneal bridge. J Bone Joint Surg Am. 1955;37:169. [PubMed: 13233281]
27. Warren MJ, Jeffree MA, Wilson DJ, MacLarnon JC. Computed tomography in suspected tarsal coalition. Examination of 26 cases. Acta Orthop Scand. 1990;61:554-557. [PubMed: 2281765]
28. McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. 1997;17:13-15. [PubMed: 8989693]
29. Swiontkowski MF, Scranton PE, Hansen S. Tarsal coalitions: long-term results of surgical treatment. J Pediatr Orthop. 1983;3:287-292. [PubMed: 6874924]
30. Heron JR. Neurological syndromes associated with pes cavus. Proc R Soc Med. 1969;62:270-271. [PubMed: 4181287]
31. Samilson RL, Dillin W. Cavus, cavovarus, and calcaneocavus. An update. Clin Orthop Relat Res. 1983;177:125-132. [PubMed: 6861385]
32. Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of a surgical approach using selective soft-tissue procedures. J Bone Joint Surg Am. 1980;62:942-953. [PubMed: 7430182]
33. Mosca VS. The cavus foot. J Pediatr Orthop. 2001;21:423-424. [PubMed: 11433149]
34. Kalen V, Brecher A. Relationship between adolescent bunions and flatfeet. Foot Ankle. 1988;8 :331-336. [PubMed: 3402852]
35. Scranton PE, Jr, Zuckerman JD. Bunion surgery in adolescents: results of surgical treatment. J Pediatr Orthop. 1984;4:39-43. [PubMed: 6693566]
36. Phelps DA, Grogan DP. Polydactyly of the foot. J Pediatr Orthop. 1985;5:446-451. [PubMed: 4019759]

redpajama_set_name: RedPajamaCommonCrawl


text:
Hradiště Levousy je raně středověké a snad i pravěké hradiště jižně od obce Křesín v okrese Litoměřice. Nachází se v polohách Na Šancích a Na Hradbách na ploché ostrožně na pravém břehu řeky Ohře.

Historie
Lokalita byla osídlena již v pravěku. Z neolitu pochází nálezy keramiky kultury s lineární keramikou, kultury s vypíchanou keramikou a lengyelské kultury z přelomu neolitu a eneolitu. Z eneolitu pochází keramika kultury kulovitých amfor. Dále byly nalezeny artefakty únětické kultury ze starší doby bronzové, mohylové kultury ze střední doby bronzové a štítarské kultury z pozdní doby bronzové. Později zde existovalo osídlení v době halštatské, laténské a době hradištní.

Stavební podoba
Hradiště je rozděleno dvěma souběžnými valy na akropoli a dvě předhradí. Celková rozloha hradiště činí 12,1 hektaru. Největší plochu s rozlohou 7,7 hektaru zabírá předhradí vnější, které je z nejpřístupnější jižní strany chráněno valem. Tento vnější val je velmi dobře zachován, místy dosahuje výšky 3,5 metru a je lemován dva metry hlubokým příkopem. Střední val je výrazně poničen orbou a vnitřní val dosahuje 2–3,5 metru. V roce 1967 byl proveden průzkumný řez vnitřním valem, který odhalil pozůstatky dřevohlinité hradby roštové a komorové konstrukce opatřené kamennou plentou, původní výška byly odhadnuta až na devět metrů. Střepový materiál datoval hradbu od konce devátého do desátého století.

Odkazy

Reference

Související články
 Seznam hradišť v Ústeckém kraji

Externí odkazy

Křesín
Přírodní park Dolní Poohří
Hradiště v okrese Litoměřice
Hradiště v Dolnooharské tabuli
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Home Community Font Bureau: An international type foundry has Martha's Vineyard roots
Font Bureau: An international type foundry has Martha's Vineyard roots
Kelsey Perrett
When it comes to fonts, most of us are passive consumers. Type is under our noses all day long — in our TV commercials, our websites, our magazines and newspapers. But most of us — at least those of us who aren't designers — don't think much about where it comes from. As it turns out, there is a whole industry surrounding fonts, and some of the most exciting innovation in the business is coming from Martha's Vineyard.
The Font Bureau was founded in 1989 by Roger Black and noted type designer David Berlow, a resident of West Tisbury. David's brother, Sam Berlow, joined as general manager, splitting his time between the Vineyard, Vermont, and the company's headquarters in New York and Boston. In June, the Font Bureau launched Type Network, a sort of "digital mall" where foundries (companies that design or distribute typefaces) can collaborate to make their fonts available to a global marketplace. Sam Berlow is president, and David serves on the board of directors.
The launch of Type Network is just one channel through which the company has risen to meet the ever-evolving technology of the digital age. The Font Bureau was initially created to serve magazine and newspaper publishers grappling to preserve their typographic brand identities as printing moved from traditional presses to digital methods.
"We started off with two markets," Sam Berlow told The Times. "One was the systems software developers, like Apple and Microsoft, who wanted fonts in their computers so their users could have a large selection of type. The other market was publications. Publications wanted their computers to have the same type that they used to set in metal or in wood."
The foundry's first customers included major papers and magazines: the Wall Street Journal, the New York Times, the Washington Post, Rolling Stone, Sports Illustrated, Time, and Newsweek. "Eventually, our clients were almost everyone you'd see on the newsstands," Mr. Berlow said. And before long, that reach expanded to European and South and Central American markets.
"The world of type went from about 8,000 typefaces to 250,000 typefaces in the course of about 20 years," Mr. Berlow said. "That's a pretty big change."
"The biggest change can be seen in television advertising," Mr. Berlow said. When TV ads first arrived, words were hand-lettered on a print poster. Even until the early 2000s, computer font choices were limited. "Now when you look at a Toyota trucks commercial, you have fonts stacking and crumbling and doing all this really wild stuff. You have really big strong block letters that look like they are made of stone, and they are just hammering in this message how strong these trucks are — but with type."
In the past decade, the Font Bureau's clientele have grown to include an array of corporations: Ford, American Express, ESPN, insurance companies, banks, pharmaceuticals. "Whatever typeface they use on their packaging, they want to use on their website, in their print advertising, on TV," Mr. Berlow explained. "So they'll buy a typeface and use it everywhere, to retain that same look and feel."
Fonts are sold based on licenses. There are separate licenses for different uses; desktop, web, applications, and ePubs. Costs then vary based on number of publications, webpage views, or length of use.
"Most companies use the same fonts in print and on the web. That's an additional license fee. That's obviously been good for business," Mr. Berlow said. "What's been even better is that new web-only companies like ESPN and Slate decided they wanted unique typefaces, so they use high-quality web fonts. That's been great for business. There are a heck of a lot more websites than there are print publications. They don't want to use the standard system fonts, they want something unique that stands out and is more flexible. So they get special web fonts from companies like us."
That's where Type Network came in: to make finding that unique, flexible font (and the appropriate licenses) easier on designers. It also makes selling fonts much easier for small independent foundries.
"It's hard for somebody to create their own [type] brand and get the exposure and the marketing and the technology to make their brand available," Mr. Berlow said. "The tools to build fonts for all of these platforms, the technology to distribute to all of those uses, is very complicated. So we decided that we would share it." For a relatively small fee, foundries can add their fonts to Type Network. "The idea is to get a group of likeminded people who are designers and developers into one store, to make it easier for customers."
Another business might have tried to dominate the market with their tools and technology, rather than share the platform with other designers. But that's not what Font Bureau is about. "Font Bureau has always been the kind of company that develops products and methodology that gets shared," Mr. Berlow said. "It's always been an internship/apprenticeship-type company. David learned how to draw type from a very famous type designer, Matthew Carter. David took that experience and taught dozens and dozens of other designers how to draw type. A lot of famous designers have come of that apprenticeship. So it's always been part of the culture to bring younger type designers in and teach them how to start their own foundry or brand, which opens it up for type designers to be as creative, and as independent as possible."
That creativity and independence has allowed Font Bureau designers the freedom to dream up the future of fonts. Fonts that are endlessly customizable when it comes to weight, width, and more. Fonts that flex from screen to screen. Fonts that make you want to keep reading them. Or stop reading. And just look.
For more information on the Font Bureau and Type Network, visit typenetwork.com.
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3-D Periodic chart designed to be cut out and folded.
Subject Chemical elements, Periodic law, Periodic table of the elements, Instruments for Research and Industry, Scientific illustration, and Milford, David C.
Depiction of the periodic table with an emphasis on the elements which receive the most attention in general chemistry textbooks.
Subject Chemical elements, Periodic law, Periodic table of the elements, Instruments for Research and Industry, Scientific illustration, and Trimble, Russell F.
A 32 column version of the step-pyramid form of the periodic table designed by William Jensen for use in an advanced level inorganic chemistry course.
A Periodic Chart depicting the relative abundance of the elements.
Subject Chemical elements, Periodic law, Periodic table of the elements, Instruments for Research and Industry, Scientific illustration, and Sheehan, William F.
An amusing rendering of the Periodic table noting the uses for some of the most well-known elements.
Creator Hortenstine, John T., Jr.
A whimsical rendering of the Periodic Table with an emphasis on the elements which are used as primary, secondary or micro nutrients for plants.
Rendering of the Periodic Table of Elements containing geographical names around the world and universe which were or may have been derived from the names of chemical elements.


We're about a couple of weeks into Houston Restaurant Weeks, so we thought it was time we tried out a new restaurant. This week's pick is Fusion Taco.
What started off as a food truck is now a fast-casual restaurant in The Heights serving tacos that go far beyond your typical Tex-Mex. This is what made us want to go. We're huge taco lovers and can always appreciate a different variety.
Fusion Taco has its own parking lot, so we were able to find a spot with no problem. However, we also went on a Sunday, but if you plan on visiting during peak Happy Hour times, prepare to wait on a spot or park on the street.
The inside of the restaurant is nice, with a bar off to the right of the main entrance and plenty of high seating and regular tables. There's also an outdoor patio, but we opted for indoors. When we asked for a Houston Restaurant Weeks menu, they said they didn't have any and instead told us what the special was: your choice of appetizer/side plus two tacos of your choice and churros with ice cream.
We asked for a carafe of mimosas and were told they didn't have any orange juice to make them. Sooooo, like there's no other kind of juice either? That was strange. We decided on margaritas instead – watermelon on the rocks and frozen strawberry. What we received? Watermelon on the rocks and frozen regular margarita. (insert face palm emoji). Luckily, we're not particular on flavors. They both tasted very good.
We tried the porky pig queso (chili con queso with smoked pork shoulder and roasted corn salsa) and the skinny queso (chili con queso, guacamole and pico). All queso selections come with a basket of house-made tortilla chips. The porky pig queso was delicious! The smokiness of the tender pork shoulder kicked it up a notch. Now the skinny queso seemed to be missing the guacamole (insert another face palm emoji), but it tasted fine without it.
Tacos of choice were as follows: BBQ Berkshire Pork (with roasted corn salsa, grilled onions and black beans), Blackened Tilapia (with pineapple salsa, chipotle crema and avocado) and the Steak and Egg (with cotija cheese and salsa verde). So here's what's not up for debate about Fusion Taco – they know what they're doing with their tacos! Sooooo delicious. Good flavors that complement each other. And they do pork right – it's so tender and flavorful. All their sauces are made in house as well. We definitely want to come back and try more tacos – we've heard good things about their lamb keema and chicken tikka masala. Their Happy Hour has rave reviews on Yelp, so can definitely see another visit in our future.
Oh yeah – we almost forgot about the churros. They didn't impress us. The accompanying ice cream was good, though. All in all, the Houston Restaurant Weeks brunch offering was $20 and it was a good value. Would definitely return — for Happy Hour — and load up on tacos and margaritas!
Fusion Taco is located at 4706 N. Main Street, Houston, TX 77009.
Side Note: Fusion Eats, from the same owners as Fusion Taco (and from what we can tell, offers a same or extremely similar menu), opened last month in Greenway Plaza.
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It was supposed to be a vacation - and a chance to get to know one another better. But when a massive storm sets in without warning, four kids are shipwrecked alone on a rocky, jungle island in the middle of the South Pacific. No adults. No instructions. Nobody to rely on but themselves. Can they make it home alive? A week ago, the biggest challenge Vanessa, Buzz, Carter, and Jane had was learning to live as a new, blended family. Now the four siblings must find a way to work together if they're going to make it off the island. But first they've got to learn to survive one another.
This is the first of three exciting adventures from multi-Emmy Award winning host of Survivor, Jeff Probst and New York Times best-selling Chris Tebbetts!
When I bought this book I wasn't aware it was a " tune in again next time " story.
I liked The tension that the story produced. It is believable. What I didn't like was the cliffhanger! I'll have to get the next book I guess.
This book was just getting good when it ended. If there isn't a sequel I will return and change my overall rating to one star.
The narrator was good but there was nothing special about the narration.
Could you see Stranded being made into a movie or a TV series? Who should the stars be?
This book would never make a good movie because there is no ending. It just stopped. As far as a TV series I might watch it only if I knew it continued beyond the end of the book.
Yes, have it be an actual novel with an ending.
No, it has no ending.
I don't remember why I bought this book for kids in audiobook. Probably it was priced really low, and as a Survivor fan, I thought it would be a fun read. This is the first of three books in a series, and sort of the first in six because the kids get shipwrecked a second time. What I didn't know is that the authors broke up one book into three parts.
I HATE being forced to buy more books just to reach a resolution of one story. There are a number of series I have never finished reading because I was so irritated that the author left me hanging. And I've never bought more books by those authors either. This is going to be another one of them. I won't know how the characters survive until they are rescued, but I can live with it. The authors should have been more considerate of their readers.
I would recommend it to a friend for a road trip with kids... possibly. I was not too thrilled with the narrator and I know kids would be so even less. But the story is about siblings coming together after a shipwreck, good story, boring narrator. Kids that like the Boxcar Children series may like this.
I listened to this out of curiosity about Jeff Probst's book series. I kept an open mind that I was not exactly the intended audience.. it is written for children around age 7 to 12 I would say. It reminded me of some of my favorite book series when I was that age a big difference though was the lack of, what I will call, an unsolvable solvable mystery. This book was a stage setter and descriptive but lacked a sense of urgency and purpose for the characters (maybe it was just the narrator though..).
Would you be willing to try another one of Charles Carroll's performances?
Not enough in this book for a movie, possibly if combined with the series.
Robinson Crusoe meets Survivor meets Boxcar Children... potential. I will have to continue reading the series to see how it works out.
This shouldn't be a series!
Would you try another book from Jeff Probst and Chris Tebbetts and/or Charles Carroll?
Maybe, but only if the price is right. This is the first book in a series of 3, but it's less than 3 hours of listening! The three books should be combined into one, at least for the price.
Jane. She has the most sense of any of them.
Maybe a movie if it includes all 3 books in the series. There isn't enough material for a TV series.
Lower the price of the next two books. They shouldn't cost as much as a book with 8 or more hours of listening! All three books just barely add up to that.
only part of the story.
Only part of the story. You have to buy 2 more books. Book 1 is not complete like the books of a series. It's just the first third of the story. Other than that, it is ingesting and pretty well done.
Great read. C an't wait until the next one.


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Fiction > Modern & contemporary fiction
Fiction > Short stories
Safe as Houses (Paperback)
Marie-Helene Bertino (author)
Usually dispatched within 5 working days
Safe as Houses, the debut story collection of Marie-Helene Bertino, proves that not all homes are shelters. The titular story revolves around an aging English professor who, mourning the loss of his wife, robs other people's homes of their sentimental knick-knacks. In ""Free Ham,"" a young dropout wins a ham after her house burns down and refuses to accept it. "Has my ham done anything wrong?" she asks, when the grocery store manager demands that she claim it.
In ""Carry Me Home, Sisters of Saint Joseph,"" a failed commercial writer moves into the basement of a convent and inadvertently discovers the secrets of the Sisters of Saint Joseph. A girl, hoping to talk her brother out of enlisting in the army, brings Bob Dylan home for Thanksgiving dinner in the quiet, dreamy ""North Of."" In "The Idea of Marcel," Emily, a conservative, elegant girl, has dinner with the idea of her ex-boyfriend, Marcel. In a night filled with baffling coincidences, including Marcel having dinner with his idea of Emily, she wonders why we tend to be more in love with ideas than with reality. In and out of the rooms of these gritty, whimsical stories roam troubled, funny people struggling to reconcile their circumstances to some kind of American Ideal and failing, over and over.
The stories of Safe as Houses are magical and original and help answer such universal and existential questions as: How far will we go to stay loyal to our friends? Can we love a man even though he is inches shorter than our ideal? Why doesn't Bob Dylan ever have his own smokes? And are there patron saints for everything, even lost socks and bad movies?
All homes are not shelters. But then again, some are. Welcome to the home of Marie-Helene Bertino.
Publisher: University of Iowa Press
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Francine Toon
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Tracy Chevalier
A Song for the Dark Times