Congenital limb deformities represent a diverse spectrum of musculoskeletal conditions that may significantly affect limb function, mobility, physical development and quality of life. Advances in prenatal diagnosis, imaging, reconstructive surgery, prosthetic technology and multidisciplinary rehabilitation have expanded the options available for managing these complex conditions. Nevertheless, determining the most appropriate treatment remains challenging, particularly when the affected limb is severely malformed, functionally limited or associated with significant anatomical abnormalities. This inaugural lecture explores the principles and evolution of congenital limb deformity management through three fundamental approaches: replacement, repair and removal. Replacement encompasses the use of prosthetic devices and reconstructive alternatives to restore function when normal anatomy cannot be achieved. Repair focuses on limb-preserving strategies, including corrective osteotomy, soft-tissue reconstruction, limb lengthening and deformity correction, to optimise function and promote long-term musculoskeletal development. Removal, including surgical amputation or ablative procedures in selected cases, may offer a functional alternative when limb preservation is unlikely to provide a satisfactory outcome. The lecture examines the clinical, functional, ethical and psychosocial considerations that influence treatment decisions, emphasising that no single approach is universally appropriate. Instead, management should be individualised according to the type and severity of the deformity, anticipated functional outcomes, growth potential, available resources and the preferences of the child and family. By integrating advances in surgical techniques, prosthetic innovation, rehabilitation and shared decision-making, this lecture advocates a patient-centred approach that prioritises function, independence and quality of life. Ultimately, the central question is not simply whether a limb should be replaced, repaired or removed, but which treatment offers the individual the best opportunity to achieve meaningful function and participate fully in everyday life.