BACKGROUND Lipomeningocele is the most common cause of occult spinal dysraphism and spinal cord tethering. Children with this condition seem normal at birth except for cutaneous signs, and the initial complaints are usually musculoskeletal. We studied the orthopaedic deformities observed in this condition. METHODS We reviewed the medical charts of 159 patients with a diagnosis of lipoma of the lumbosacral spine that were examined in the Myelodysplasia Clinic over 25 years. Of these patients, 122 were treated by a single orthopaedic surgeon (L.D.) and were studied in detail. Of these 122 patients, 45 were over 15 years of age at the time of the final follow-up. RESULTS Most patients had cutaneous stigmata. Foot deformities were the most common orthopaedic problems, followed by scoliosis. In patients over 15 years of age, the incidence of foot deformities was 44.2% (36 feet), with 20 feet requiring surgical treatment. The most common foot deformities were cavovarus, cavus, and equinocavovarus. In 70% of the surgical cases, good correction was achieved with only one procedure. Foot surgeries in patients under the age of 8 years were usually soft tissue procedures, and bony procedures were performed primarily in patients over the age of 11 years. CONCLUSIONS Orthopaedic deformities are common at the initial presentation in patients with occult spinal dysraphism. A careful clinical examination with a high index of suspicion for spinal cord anomalies is indicated in all cases of spinal and lower extremity deformities. Foot deformities are very common and surgical treatment is usually successful. A thorough follow-up evaluation, including manual muscle strength testing, should be performed routinely to detect tethering of the cord in the early stages and to prevent worsening of the orthopaedic deformities. METHODS This was a retrospective case study. Level 4.