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Purpose: This study was performed to investigate leg-length discrepancy (LLD) and associated risk factors after paediatric femur shaft fractures. Methods: A total of 72 consecutive patients under 13 years old (mean age 6.7 years; 48 boys, 24 girls) with unilateral femur shaft fracture, and a minimum follow-up of 18 months, were included. The amount of LLD was calculated by subtracting the length of the uninjured from that of the injured limb. Risk factors for an LLD = 1 cm and = 2 cm were analyzed using multivariable logistic regression analysis. Results: Hip spica casting, titanium elastic nailing and plating were performed on 22, 40 and ten patients, respectively. The mean LLD was 7.8 mm (sd 8.8) and 29 (40.3%) had a LLD of = 1 cm, while nine (12.5%) had a LLD of = 2 cm. There were significant differences in fracture stability (p = 0.005) and treatment methods (p = 0.011) between patients with LLD < 1 cm and = 1 cm. There were significant differences in fracture site shortening (p < 0.001) and LLD (p < 0.001) between patients with length-stable and length-unstable fractures. Fracture stability was the only factor associated with LLD = 1 cm (odds ratio of 4.0; p = 0.020) in the multivariable analysis. Conclusion: This study demonstrated that fracture stability was significantly associated with LLD after paediatric femur shaft fractures. Therefore, the surgeon should consider the possibility of LLD after length-stable femur shaft fracture in children. [ABSTRACT FROM AUTHOR]

Background: Having observed a tendency towards femoral overgrowth (FO) of the affected limb in children with atrophic-type congenital pseudarthrosis of the tibia (CPT), we aimed to identify the incidence of, contributors to, and patterns of FO among such children.Methods: We retrospectively evaluated 55 children with CPT, 22 with prepseudarthrosis and 33 with atrophic-type CPT from 1989 to 2012. FO was defined as an affected femoral segment ≥10 mm longer than the contralateral segment. We investigated FO incidences in prepseudarthrosis versus atrophic-type CPT. Sex, laterality, coexistence of neurofibromatosis type 1, development of frank pseudarthrosis, extent of tibial shortening, shortening in foot height, deformity severity, distraction osteogenesis (DO) treatment, refracture, increased femoral neck-shaft angle, tibiofemoral angle, and ankle valgus angle were investigated to identify potential contributors to FO. Patterns of FO were also determined.Results: At initial presentation, 11 patients exhibited a mean of 13 mm (10-23) of FO. However, the nature of FO changed over time during the follow-up period (mean, 10.8 years; range, 4.3-19.3). At the last follow-up, 14 patients presented with a mean of 12 mm (10-18) of FO. With the exception of one patient, all patients with FO presented with atrophic-type CPT. Frank pseudarthrosis, DO treatment, and increased femoral neck-shaft angle were significantly associated with FO (p = 0.016, p = 0.001, and p = 0.005, respectively). Diverse patterns of FO were observed.Conclusions: FO of the affected limb is frequently encountered in patients with atrophic-type CPT. A compensatory response to frank pseudarthrosis, DO treatment, and neurofibromatosis may play a role in the diverse patterns of FO. [ABSTRACT FROM AUTHOR]

Background: Although ankle fracture surgery can affect glycemic control by either trauma-induced stress or a postoperative decrease in physical activity, there is little evidence on this issue. This study aimed to evaluate the influence of ankle fracture surgery on glycemic control and to assess the risk factors for poor glycemic control after surgery in patients with diabetes.Methods: We reviewed the medical records of consecutive patients with diabetes who underwent open reduction and internal fixation for the treatment of ankle fracture at our hospital. Patients who underwent blood testing, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and cholesterol levels, as part of a routine check-up before surgery and again more than 2 times after surgery were included. Changes in blood test results were adjusted by multiple factors using a linear mixed model with sex, age at time of surgery, body mass index (BMI), and type of ankle fracture as the fixed effects and each subject and timing of blood test as the random effects.Results: Sixty patients were ultimately included in this study. At 1 month postoperatively, mean FBG and cholesterol levels had increased significantly compared with preoperative levels (p = 0.011 and 0.024, respectively). After surgery, FBG levels showed an estimated monthly decrease of 2.2 mg/dL (p = 0.017). Sex, age at time of surgery, and type of ankle fracture did not significantly affect the monthly change in FBG level. FBG returned to the preoperative level at an estimated period of 8.1 months. BMI significantly affected preoperative FBG level (p = 0.015) but not the postoperative change in FBG level (p = 0.500).Conclusion: Ankle fracture surgery increased the FBG level at 1 month postoperatively. FBG levels decreased gradually after surgery at an estimated monthly rate of 2.2 mg/dL. Physicians should be aware of the difficulty in postoperative blood glucose control in patients with diabetes, even several months after surgery. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 71-year-old woman with pain and swelling of the right great toe and who was diagnosed with epidermoid inclusion cysts.

Background: The prevalence of idiopathic planovalgus decreases with age among children and adolescents. Previous studies have provided averages of radiographic indices for different age groups but not information about the rate of spontaneous correction and the affecting factors. The aim of this study was to estimate the rate of spontaneous improvement of radiographic indices of idiopathic planovalgus through the application of a linear mixed model. Methods: We included patients with idiopathic planovalgus who were no older than the age of fifteen years, who had had two or more weight-bearing foot radiographs made, and who were followed for more than one year. The talonavicular coverage angle, the anteroposterior talus-first metatarsal angle, the calcaneal pitch angle, and the lateral talus-first metatarsal angle were measured on the radiographs. The rate of angular correction was adjusted by multiple factors with the use of a linear mixed model, with sex and laterality as the fixed effects and age and each subject as the random effects. Results: A total of 568 feet were included in this study, and a total of 3284 radiographs were measured. The talonavicular coverage angle was found to have decreased by 1.7° per year (p < 0.001); the anteroposterior talus-first metatarsal angle, by 2.1° per year (p < 0.001); and the lateral talus-first metatarsal angle, by 0.7° per year (p = 0.034). The spontaneous improvement of the calcaneal pitch with aging was not significant. Conclusions: The talonavicular coverage angle and the anteroposterior talus-first metatarsal angle on anteroposterior radiographs and the lateral talus-first metatarsal angle on lateral radiographs improved as patients with idiopathic planovalgus grew older. These findings can assist in the prediction of the radiographic improvement of idiopathic planovalgus. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

A questionnaire survey was performed to investigate the different knowledge of radiation exposure, awareness and expectation for O-arm imaging system between the users (orthopaedic surgeons) and the developers (engineers). A total of 93 orthopaedic surgeons and 19 engineers participated and answered the questionnaire consisting of 18 items designed for this study. The items were focused on knowlege, awareness, and expectation. Orthopaedic surgeons had higher scores for items of knowledge domains regarding radiation exposure than the engineers while the engineers were more sensitive to radiation hazards and adopted higher levels of radiation protection than orthopaedic surgeons in the awareness domain. Most engineers and orthopaedic surgeons answered that the requirements of diagnostic and intraoperative imaging systems differ. Image resolution, a low radiation exposure, and the time required for image acquisition was the top three requirements of O-arm selected by engineers. On the other hand, the top three requirements according to orthopaedic surgeons were; image resolution, expediency, and spatial occupancy. User requirements need to be reflected in developing O-arm along with basic requirements such as image resolution and low radiation exposure. [ABSTRACT FROM AUTHOR]

Background: Statistical independence means that one observation is not affected by another; however, the principle of statistical independence is violated if left and right-side measures within a subject are considered to be independent, because they are usually correlated and can affect each other. The purpose of the present study was to analyze the violation of statistical independence in recent orthopaedic research papers and to demonstrate the effect of statistical analysis that considered the data dependency within a subject. Methods: First, all original articles that had been published in The Journal of Bone and Joint Surgery (American Volume) over a two-year period were evaluated. The analysis was designed to identify articles that included bilateral cases and possible violations of statistical independence. Second, a demonstrative logistic regression without consideration of statistical independence was performed and was compared with a statistical analysis that considered data dependency within a subject. Radiographs of 1200 hips in 600 patients were used to examine the differences in terms of odds ratios (with 95% confidence intervals) of the risk factors for hip osteoarthritis. Results: Four hundred and eighty-six original articles were reviewed, and 151 articles (including forty-one articles involving the hip, thirty-four involving the knee, twenty-one involving the foot or ankle, nineteen involving the shoulder, ten involving the hand or wrist, nine involving the elbow, and seventeen involving other structures) were considered to include bilateral cases. Of the 486 articles that were reviewed, 120 articles (25%) (including thirty-six articles involving the hip, twenty-six involving the knee, fifteen involving the foot or ankle, fourteen involving the shoulder, seven involving the elbow, six involving the hand or wrist, and sixteen involving other structures) were found to have possibly violated statistical independence. Demonstrative statistical analysis showed that logistic regression was not robust to the violation of statistical independence. The 95% confidence intervals of the odds ratios for the risk factors showed narrower ranges (1.13 to 2.68 times) when data dependency within a subject was not considered. Conclusions: Researchers need to consider statistical independence when performing statistical analysis, particularly in studies involving bilateral cases. If data dependency within a subject is not considered, studies involving bilateral cases can bias results, depending on the context of those studies. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to analyze kinematic trunk motion data in normal adults and to investigate gender effect. Methods: Kinematic trunk motion data were obtained for 20 healthy subjects (11 men and 9 women; age from 21 to 40 years) during walking a 9 m long lane at a self selected speed, namely, motions in the sagittal (tilt), coronal (obliquity), and transverse (rotation) planes, which were all expressed as motions in global (relative to the ground) and those in pelvic reference frame (relative to pelvis), i.e., tilt (G), obliquity (G), rotation (G), tilt (P), obliquity (P), rotation (P). Results: Range of tilt (G), obliquity (G) and rotation (G) showed smaller motion than that of tilt (P), obliquity (P) and rotation (P), respectively. When genders were compared, female trunks showed a 5 degree more extended posture during gait than male trunks (p = 0.002), which appeared to be caused by different lumbar lordosis. Ranges of coronal and transverse plane motion appeared to be correlated. In gait cycle, the trunk motion appeared to counterbalance the lower extremity during swing phase in sagittal plane, and to reduce the angular velocity toward the contralateral side immediate before the contralateral heel strike in the coronal plane. Conclusions: Men and women showed different lumbar lordosis during normal gait, which might be partly responsible for the different prevalence of lumbar diseases between genders. However, this needs further investigation. [ABSTRACT FROM AUTHOR]

γ-aminobutyric acid receptors (GABABRs) are G-protein coupled receptors mediating the slow-onset and prolonged synaptic actions of GABA in the central nervous system (CNS). There are two subtypes, GABAB1R and GABAB2R, that are though to form het- erodimers, with the GABAB1R subunit essential for ligand binding and the GABAB2R subunit for cell surface localization. We have analyzed the distribution of GABAB1R and GABAB2R transcripts by in situ hybridization. The tyro transcripts were generally expressed in parallel, and the highest levels were detected in the piriform cortex, hippocampus, medial habenula, and olfactory bulb. There was moderate expression in several thalamic nuclei and the cortex area. In contrast to the distribution of GABB2R mRNA. GABAB1R gave weak signals throughout the thalamus, piriform cortex, and field CA2 of the hippocampus, but strong signals in the septum, superior colliculus, retrosplenial cortex area. and field CAI of the hippocampus. Thus GABAB2R and GABAB1R mRNA expression overlapped considerably, consistent with the suggestion that the two subtypes assemble to form a heterodimer. There are nevertheless differences in their expression levels that suggest at the existence of unidentified receptor subtypes. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 10-year-old Korean boy suffering from tenderness and pain with movement of the right hip. The magnetic resonance imaging scan of the hip shows a segmented rim-enhancing lesion at the right femoral shaft, with increase signal intensity. The patient gradually improves on antibiotics after performing the surgical drainage and curettage of the lesion.

Purpose This study evaluated the rates and annual trends of pediatric CT scans in South Korea using a nationwide population-based database. Materials and Methods Data regarding pediatric CT scan usage between 2012 and 2017 were retrieved from the health insurance review and assessment service. Data on the age, sex, diagnosis, and the anatomical area of involved patients were also extracted. Results A total of 576376 CT examinations were performed among 58527528 children aged below 18 years (9.8 scans/1000 children), and the number of CT examinations per 1000 children was noted to have increased by 23.2% from 9.0 in 2012 to 11.0 in 2017. Specifically, the number of CT examinations increased by 32.9% for the 6–12 years of age group (7.4/1000 to 9.8/1000) and by 34.0% for the 13–18 years of age group (11.4/1000 to 15.3/1000). Moreover, majority of the CT scans were limited to the head (39.1%), followed by the extremities (32.5%) and the abdomen (13.7%). Notably, the number of extremity CT scans increased by 83.6% (2.3/1000 to 4.2/1000), and its proportion as compared to other scans increased from 25.3% to 37.7%. Conclusion CT scans in the pediatric population increased continuously from 2012 to 2017 at an annual rate of 4.4%. Therefore, physicians should balance the benefits of CT with its potential harms from associated radiation exposure in pediatric patients. [ABSTRACT FROM AUTHOR]

Background: The purposes of this study were to evaluate acetabular remodeling after closed reduction of developmental dysplasia of the hip (DDH) and to delineate the role of osteotomy.Methods: Eighty-four hips with DDH treated with closed reduction and followed until the patient was 8 years of age or older were included in this study. The mean age at closed reduction was 14.0 months (range, 3 to 30 months) and that at the latest follow-up visit was 12.7 years (range, 8.0 to 24.7 years). Osteotomy was performed in 26 hips (31%) during the follow-up period, at an average age of 2.8 years (range, 2.0 to 5.8 years). The acetabular index (AI) and center-edge angle (CEA) were measured, and osteonecrosis was graded. The treatment outcome was evaluated as satisfactory (Severin grade I or II) or unsatisfactory (III or IV). We retrospectively analyzed the associations among radiographic parameters, performance of osteotomy, grade of osteonecrosis, and final outcome.Results: A satisfactory outcome was observed in 67 (80%) of the 84 hips. An osteotomy was not performed in 30 of 34 hips with an AI of <32° and a CEA of >14° at the age of 3 years, and 28 (93%) of these 30 hips showed a satisfactory outcome. Of the 33 hips with an AI of ≥32° and a CEA of ≤14° at the age of 3 years, the 20 that had undergone an osteotomy showed a higher proportion of satisfactory outcomes than the 13 hips that had not (p = 0.01). Three of the 4 hips that showed an unsatisfactory outcome following an osteotomy had an AI of ≥34° at 1 year post-osteotomy. Grade-II, III, or IV osteonecrosis, according to the Bucholz-Ogden classification, developed in 10 of the 84 hips, and these 10 hips had a higher proportion of unsatisfactory outcomes than did those that developed no or grade-I osteonecrosis (p = 0.004).Conclusions: Hips with DDH showing poor acetabular remodeling after closed reduction may benefit from osteotomy. The AI and CEA at the age of 3 years can serve as one of the guidelines for osteotomy. Continued surveillance for acetabular remodeling is required even after osteotomy.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article presents a study which measured surgeons' exposure to ionizing radiation dose during intraoperative use of C-arm fluoroscopy in spine surgery, conducted by Kisung Lee et al. The objective of the study is to assess scatter radiation doses to specific organs during intraoperative use of C-arm fluoroscopy in spine surgery. The research determined the factors that could reduce radiation exposure including distance from the patient and radioprotective equipment.

Background: Clinical decision-making in the treatment of foot deformities is based primarily on the results of the physical examination and the radiographic findings. The purpose of this study was to determine the validity and reliability of commonly used radiographic measurements of hind foot valgus and varus deformities. Methods: Seventy-two patients with hind foot deformity (thirty-six hind foot valgus, mean age 15.5 years; thirty-six hind foot varus, mean age 30.2 years) were evaluated. Nine representative indices on weight-bearing radiographs were assessed. Three examiners measured the radiographic indices at two sessions, and intra observer and inter observer reliability was determined. Discriminant validity of the radiographic measurements between hind foot valgus and varus was evaluated. The correlation with pedobarographic findings in evaluating the distribution of foot pressure during gait was assessed for convergent validity. Results: Naviculocuboid overlap, anteroposterior talonavicular coverage angle, anteroposterior talus-first metatarsal angle, calcaneal pitch angle, and lateral talus-first metatarsal angle showed excellent reliability. Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-first metatarsal angle showed excellent discriminant validity (in terms of effect-size r) and convergent validity (in terms of correlation coefficients with pedobarography). Conclusions: Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-first metatarsal angle are reliable and valid measures for the evaluation of hind foot valgus and varus deformities. Level of Evidence: Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Increased femoral anteversion and coxa valga are common in patients with cerebral palsy. The purpose of the present study was to determine the validity and reliability of the methods that are commonly used to measure the proximal femoral geometry in patients with cerebral palsy. Methods: Thirty-six consecutive patients (mean age, eleven years; range, five to twenty years) with cerebral palsy were enrolled in the present study. The validity and the interobserver reliability of the physical examinations performed by three examiners were determined by comparing the results of a trochanteric prominence angle test, hip internal rotation measurements, and hip external rotation measurements (all with the patient in the prone position) with the amount of femoral anteversion on two-dimensional computed tomography. Validity and intraobserver and interobserver reliability were assessed by comparing the neck-shaft angle on the anteroposterior internal rotation radiograph of the hips with that on the multiplanar reformatted computed tomographic image. Results: The trochanteric prominence angle test showed excellent concurrent validity (R = 0.862, p < 0.001) and reliability (intraclass correlation coefficient, 0.809). Hip internal rotation also showed good concurrent validity (R = 0.787, p < 0.001) and excellent reliability (intraclass correlation coefficient, 0.889), whereas hip external rotation appeared to be unsuitable for predicting femoral anteversion. The neck-shaft angle on the anteroposterior internal rotation radiograph of the hips showed excellent concurrent validity (R = 0.892, p < 0.001) and reliability (intraclass correlation coefficient, 0.912). Conclusions: A physical examination for determining femoral anteversion and the neck-shaft angle as measured on the internal rotation radiograph of the hips appear to be clinically relevant methods for evaluating the proximal femoral geometry and version in patients with cerebral palsy. Computed tomographic examination can probably be replaced by physical examination and an anteroposterior internal rotation radiograph of the hips for patients with stable hips who are able to walk. [ABSTRACT FROM AUTHOR]

Introduction: Gonadotropin-releasing hormone (GnRH) is the pivotal hormone in the hypothalamopituitary gonadal axis. Recently, localization of extrahypothalamic GnRHs and GnRH receptors has been made in several organs but not in the bladder. We studied the extrahypothalamic GnRH and GnRH receptor in bladder cancer epithelia, and the role of GnRH on bladder cancer cell proliferation. Material and Methods: Normal human bladder mucosa, human transitional bladder cancer tissue, and 4 bladder cancer cell lines were used. For culture media, normal or charcoal-stripped serum with exogenous GnRH of different concentrations (0, 10–3, 10–5, and 10–7M) were supplemented. For detection of GnRH and the GnRH receptor and its mRNAs, RNase protection assay, in situ hybridization, and immunocytochemistry were performed. Cellular proliferation was measured by hemocytometer and the cell cycle by flow cytometer. Results: GnRH and GnRH receptor mRNA expression were detected in all cancer cell lines and human bladder cancer tissues. GnRH and GnRH receptors were localized in bladder cancer epithelial cells, but the density was not even. There were no significant differences (p > 0.05) in proliferation, and no significant change (p > 0.05) in cell cycle with GnRH supplements compared to controls. Conclusion: The bladder epithelia produce GnRH and the GnRH receptor in both normal and malignant tissues, but GnRH does not induce proliferation or cell cycle change of bladder cancer cells. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The hallux interphalangeal joint is stable in the transverse plane and there have been only a few reports of varus instability of this joint. A case is described of varus subluxation of the hallux interphalangeal joint in a taekwondo athlete and the surgical outcome after reconstruction of the collateral ligament. Taekwondo athletes, who require fast powerful kicks, should be warned about this type of forefoot injury. [ABSTRACT FROM AUTHOR]

Background: Idiopathic pes planovalgus is one of the most common foot deformities in children and adolescents. However, there is a discrepancy between subjective symptoms and radiographic severity in idiopathic planovalgus deformity, and very few studies have investigated this aspect. Further, the assessment of subjective symptoms in patients with pes planovalgus requires a quantitative scoring system for making meaningful comparisons, such as the Oxford Ankle Foot Questionnaire for Children (OxAFQ-c) and that for parents (OxAFQ-p). Therefore, the purpose of this study was to evaluate the factors affecting the symptoms of idiopathic planovalgus using the OxAFQ.Methods: All patients who were ≤18 years of age, had visited our clinic for the evaluation of pes planovalgus deformity, and had completed the OxAFQ were included in this study. The anteroposterior talo-first metatarsal, lateral talo-first metatarsal, and hallux valgus angles were measured on weight-bearing radiographs. The data were analyzed using a multiple regression model, with age, sex, and radiographic indices as explanatory variables.Results: Overall, 123 patients were enrolled in this study, and 246 standing foot radiographs were evaluated along with scores in each domain of the OxAFQ. The factors affecting physical domain scores in the OxAFQ-c were female sex (p = 0.047) and the anteroposterior talo-first metatarsal angle (p = 0.033). Age of ≥10 years was a significant factor (p < 0.05) affecting all domains in both the OxAFQ-c and OxAFQ-p other than the physical domain score.Conclusions: Although pes planovalgus deformity is 3-dimensional, the forefoot abduction component of the deformity should be carefully assessed as it is closely related to subjective symptoms. Further, in female patients with a more severe anteroposterior talo-first metatarsal angle, an aggravation of symptoms with aging should be expected when managing pes planovalgus deformity.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Although several studies have investigated the outcomes after distal hamstring lengthening (DHL), no study has undertaken an approach that included all or most of the important factors that could influence the results. This study was performed to evaluate the outcomes after DHL and analyze the factors that influence the improvement and serial change in knee motion after surgery in patients with cerebral palsy (CP), using a linear mixed model (LMM).Methods: The study included 314 ambulatory CP patients (594 limbs) with spsastic diplegia who were followed up after undergoing DHL as part of a single-event multilevel surgery and who underwent preoperative and postoperative 3-dimensional (3D) gait analyses. Relevant kinematic values, including knee flexion at initial contact, minimum knee flexion in the stance phase, knee range of motion (ROM), mean pelvic tilt and gait deviation index (GDI) score, were the outcome measures. Changes in knee motion and the GDI score were adjusted for multiple factors, such as sex, the Gross Motor Function Classification System (GMFCS) level, and concomitant surgeries as fixed effects, and follow-up duration, laterality, and each subject as random effects, using a LMM.Results: We found significant improvements in knee flexion at initial contact, minimum knee flexion in the stance phase, knee ROM, and GDI score 2 years after DHL. In patients with GMFCS level I and II, improvement in all sagittal knee kinematics was maintained during follow-up. In addition, GDI score, which represents overall gait pathology, consistently improved throughout the follow-up duration (1.2 per year, p = 0.008).Conclusion: Medial hamstring lengthening with semitendinosus transfer, as a part of a SEMLS, was effective procedure in treating flexed knee gait with regard to sagittal knee kinematics and GDI score in spastic CP with flexed knee gait. [ABSTRACT FROM AUTHOR]

Background: Intramedullary rodding has been the mainstay of long-bone stabilization in osteogenesis imperfecta. However, in some cases, intramedullary rodding cannot provide adequate fixation because of a lack of rotational control and thin diameter of long bones. We have applied adjunctive unicortical locking plate fixation in selected cases of osteogenesis imperfecta to address these biomechanical issues. Methods: Thirty-seven bone segments of twenty-four patients with osteogenesis imperfecta (ten type III, nine type IV, three type I, and two type V), in which unicortical locking plate fixation was applied adjunctive to intramedullary rodding and was later removed after union had been achieved, were the study subjects. The mean patient age at the time of surgery was 15.5 years (range, 6.2 to 39.8 years). Medical records and follow-up radiographs were reviewed to evaluate healing, complications, and the fates of screw holes after plate removal. Results: All fractures or osteotomies healed completely. Locking plates were removed postoperatively at a mean time (and standard deviation) of 1.8 ± 0.9 years (range, 0.3 to 3.8 years). In seven of the thirty-seven cases, fractures through the screw hole occurred; all of these were treated conservatively. In eighteen of nineteen cases that were followed for more than a year after plate removal without screw hole-related complication, screw holes healed and were no longer visualized by radiography. Conclusions: Unicortical locking plate fixation effectively supplements intramedullary rod fixation in selected cases of osteogenesis imperfecta. [ABSTRACT FROM AUTHOR]

Background: To compare the clinical and radiological features of intra-/juxta-articular osteoid osteoma and extra-articular osteoid osteoma in skeletally immature patients, paying special attention to the skeletal complications. Methods: Osteoid osteoma in 34 children (22 boys and 12 girls, mean age 10.4 years) was dichotomized according to the location of the nidus as intra-/juxta-articular (11 children) or extra-articular (23 children). The following features were compared: diagnostic delay, typical symptoms, synovitis and limited range of joint motion, response to treatment, typical radiographic findings, and skeletal complications. Results: Eight of the 11 children with intra-/juxta-articular osteoid osteoma presented with synovitis in the involved joint, which led to a delayed diagnosis for a median 9.5 months. Pain disappeared in all children with surgical or medical interventions, but at the mean 4.9-year follow-up evaluation, skeletal abnormalities around the joint were noted in 5 children (4 proximal femur and 1 distal humerus) with intra-/juxta-articular osteoid osteoma, 2 of whom required subsequent surgeries for limited hip motion caused by femoroacetabular impingement and limited range of elbow motion, respectively. In contrast, typical clinical and radiological features were observed more often in extra-articular osteoid osteoma, and only 1 child showed overgrowth of the tibia, which did not have clinical significance. Conclusions: Intra-/juxta-articular osteoid osteomas in growing children exhibit different clinical and radiological features from extra-articular lesions. Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma, and these may lead to permanent skeletal sequelae. [ABSTRACT FROM AUTHOR]

Background To compare the clinical and radiological features of intra-/juxta-articular osteoid osteoma and extra-articular osteoid osteoma in skeletally immature patients, paying special attention to the skeletal complications. Methods Osteoid osteoma in 34 children (22 boys and 12 girls, mean age 10.4 years) was dichotomized according to the location of the nidus as intra-/juxta-articular (11 children) or extra-articular (23 children). The following features were compared: diagnostic delay, typical symptoms, synovitis and limited range of joint motion, response to treatment, typical radiographic findings, and skeletal complications. Results Eight of the 11 children with intra-/juxta-articular osteoid osteoma presented with synovitis in the involved joint, which led to a delayed diagnosis for a median 9.5 months. Pain disappeared in all children with surgical or medical interventions, but at the mean 4.9-year follow-up evaluation, skeletal abnormalities around the joint were noted in 5 children (4 proximal femur and 1 distal humerus) with intra-/juxta-articular osteoid osteoma, 2 of whom required subsequent surgeries for limited hip motion caused by femoroacetabular impingement and limited range of elbow motion, respectively. In contrast, typical clinical and radiological features were observed more often in extra-articular osteoid osteoma, and only 1 child showed overgrowth of the tibia, which did not have clinical significance. Conclusions Intra-/juxta-articular osteoid osteomas in growing children exhibit different clinical and radiological features from extra-articular lesions. Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma, and these may lead to permanent skeletal sequelae. [ABSTRACT FROM AUTHOR]

Background: Hip instability can cause major problems in children with cerebral palsy, although good outcomes of hip reconstructive surgery for hip instability have been reported. In the present study, we investigated the recurrence of hip instability after reconstructive surgery and the factors influencing this recurrence in patients with cerebral palsy. Methods: We examined consecutive patients with hip instability related to cerebral palsy who had undergone hip reconstructive surgery including femoral varus derotational osteotomy. The neck-shaft angle, head-shaft angle, and migration percentage were measured at each postoperative follow-up evaluation. For each Gross Motor Function Classification System (GMFCS) level, annual changes in radiographic indices were adjusted for multiple factors with use of a linear mixed model, with sex as the fixed effect and laterality and each subject as the random effects. Results: A total of 144 hips (seventy-six patients) were included in this study, and 845 radiographs were evaluated. The GMFCS level was II or III for twelve patients, IV for thirty, and V for thirty-four. The neck-shaft angle showed no significant change in the patients with GMFCS level II or III (p = 0.425), IV (p = 0.106), or V (p = 0.972). The head-shaft angle showed a significant change in those with GMFCS level IV (p = 0.008) but not in those with level II or III (p = 0.201) or V (p = 0.591). The migration percentage did not change significantly in patients with GMFCS level II or III (p = 0.742), but it increased significantly by 2.0% per year (p < 0.001) in patients with GMFCS level IV and by 3.5% per year (p = 0.003) in those with level V. Conclusions: Periodic monitoring and follow-up for the recurrence of hip instability is important in patients with cerebral palsy and a GMFCS level of IV or V. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Mycobacterial osteomyelitis involving only the epiphysis of a long bone is extremely rare, and its clinical and radiographic features remain unclear. The purpose of this study was to characterize mycobacterial epiphyseal osteomyelitis and to identify differences between its features and those reported for epiphyseal osteomyelitis caused by bacteria or unidentified pathogens. Methods: We retrospectively reviewed the cases of eight children (five males and three females) who presented at a median age of nineteen months (range, twelve to twenty-five months). Clinical findings were compiled. Radiographs and magnetic resonance imaging (MRI) were used to determine local spread of the abscess outside the epiphysis during the disease course. At the time of the latest follow-up evaluation, the presence of limited joint mobility or growth disturbance was determined. Physeal damage was evaluated with use of MRI. Results: Pathogens were identified through multiplex polymerase chain reaction. Mycobacterium bovis bacille Calmette- Guérin (BCG, Tokyo-172 strain) was identified in four patients; Mycobacterium tuberculosis, in three patients; and nontuberculous mycobacterium, in one patient. The lesion was located at the distal femoral epiphysis in six patients, at the proximal tibial epiphysis in one patient, and at the proximal humeral epiphysis in one patient. The abscess was confined to the epiphysis at the time of initial presentation but, over time, extended outside the epiphysis in seven cases. The lesion was initially located in the cartilaginous epiphysis in two patients, which could be diagnosed only on MRI. Seven patients worsened despite surgical drainage and medication, and five required additional surgery. At follow-up at a mean of 4.1 years (range, 1.3 to 7.8 years), focal physeal damage was evident in five patients, and clinical growth disturbance was evident in one patient. Conclusions: In contrast to the reported benign features of epiphyseal osteomyelitis caused by bacteria or unidentified pathogens, mycobacterial epiphyseal osteomyelitis seems to have an unfavorable clinical course that tends to lead to physeal damage. MRI is useful for early diagnosis of a cartilaginous lesion and evaluation of abscess spread and physeal damage. [ABSTRACT FROM AUTHOR]

Background: The Lauge-Hansen classification system does not provide sufficient data related to syndesmotic injuries in supination-external rotation (SER)-type ankle fractures. The aim of the present study was to investigate factors helpful for the preoperative detection of syndesmotic injuries in SER-type ankle fractures using radiographs and computed tomography (CT). Methods: A cohort of 191 consecutive patients (104 male and eighty-seven female patients with a mean age [and standard deviation] of 50.7 ± 16.4 years) with SER-type ankle fractures who had undergone operative treatment were included. Preoperative ankle radiographs and CT imaging scans were made for all patients, and clinical data, including age, sex, and mechanism of injury (high or low-energy trauma), were collected. Patients were divided into two groups: the stable syndesmotic group and the unstable syndesmotic group, with a positive intraoperative lateral stress test leading to syndesmotic screw fixation. Fracture height, fracture length, medial joint space, extent of fracture, and bone attenuation were measured on radiographs and CT images and were compared between the groups. Binary logistic regression analysis was performed to identify the factors that significantly contributed to unstable syndesmotic injuries. Receiver operating characteristic curves were calculated, and cutoff values were suggested to predict unstable syndesmotic injuries on preoperative imaging measurements. Results: Of the 191 patents with a SER-type ankle fracture, thirty-eight (19.9%) had a concurrent unstable syndesmotic injury. Age, sex, mechanism of injury, fracture height, medial joint space, and bone attenuation were significantly different between the two groups. In the binary logistic analysis, fracture height, medial joint space, and bone attenuation were found to be significant factors contributing to unstable syndesmotic injuries. The cutoff values for predicting unstable syndesmotic injuries were a fracture height of >3 mm and a medial joint space of >4.9 mm on CT scans, and a fracture height of >7 mm and medial joint space of >4.5 mm on radiographs. Conclusions: Fracture height, medial joint space, and bone attenuation were useful factors for the preoperative detection of unstable syndesmotic injuries in SER-type ankle fractures. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background Codman's paradox reveals a misunderstanding of geometry in orthopedic practice. Physicians often encounter situations that cannot be understood intuitively during orthopedic interventions such as corrective osteotomy. Occasionally, unexpected angular or rotational deformity occurs during surgery. This study aimed to draw the attention of orthopedic surgeons toward the concepts of orientation and rotation and demonstrate the potential for unexpected deformity after orthopedic interventions. This study focused on three situations: shoulder arthrodesis, femoral varization derotational osteotomy, and femoral derotation osteotomy. Methods First, a shoulder model was generated to calculate unexpected rotational deformity to demonstrate Codman's paradox. Second, femoral varization derotational osteotomy was simulated using a cylinder model. Third, a reconstructed femoral model was used to calculate unexpected angular or rotational deformity during femoral derotation osteotomy. Results Unexpected external rotation was found after forward elevation and abduction of the shoulder joint. In the varization and derotation model, closed-wedge osteotomy and additional derotation resulted in an unexpected extension and valgus deformity, namely, undercorrection of coxa valga. After femoral derotational osteotomy, varization and extension of the distal fragment occurred, although the extension was negligible. Conclusions Surgeons should be aware of unexpected angular deformity after surgical procedure involving bony areas. The degree of deformity differs depending on the context of the surgical procedure. However, this study reveals that notable deformities can be expected during orthopedic procedures such as femoral varization derotational osteotomy. [ABSTRACT FROM AUTHOR]

Background: Multiple epiphyseal dysplasia (MED) is a relatively common skeletal dysplasia mainly involving the epiphyses of the long bones. However, it is a genetically heterogeneous group of diseases sharing certain aspects of the radiologic phenotype. In surveys conducted in East Asia, MATN3 was the most common causative gene, followed by COMP. In this study, the authors compared clinical manifestation of MED patients caused by MATN3 and COMP gene mutations, as well as subsequent orthopaedic interventions. Methods: Fifty nine molecularly-confirmed MED patients were subjects of this study. The MATN3 gene mutation group comprised of 37 patients (9 female, 28 male). The COMP gene mutation consisted of 22 cases (15 females, 7 males). Medical records and radiographs were reviewed, and questionnaire surveys or telephone interviews were conducted. Results: At the first presentation, the mean age was 8.8 ± 2.8 years (mean ± standard deviation) in the MATN3 group, and 8.5 ± 3.5 years in the COMP group (p = 0.670). The height in the COMP group was significantly shorter than those in the MATN3 group (p < 0.001). Gait abnormality at the first visit (p = 0.041) and the lastest follow-up (p = 0.037) were statistically significant difference. Hip pain (p = 0.084), limitation of daily activity (p = 0.075) at the latest follow-up tended to be more frequent in the COMP group. Hip dysplasia was more common in the COMP group, having significantly larger acetabular angle (p = 0.037), smaller center-edge angle (p = 0.002), severe Stulberg classification (p < 0.001), and smaller femoral head coverage (p < 0.001). Conclusions: Clinical manifestations of MED caused by MATN3 were milder than manifestations of the COMP mutation group. These differences in clinical manifestation and prognosis justify molecular differentiation between the two genotypes. [ABSTRACT FROM AUTHOR]

This study aimed to determine the best treatment modality for coronal angular deformity of the knee joint in growing children using decision analysis. A decision tree was created to evaluate 3 treatment modalities for coronal angular deformity in growing children: temporary hemiepiphysiodesis using staples, percutaneous screws, or a tension band plate. A decision analysis model was constructed containing the final outcome score, probability of metal failure, and incomplete correction of deformity. The final outcome was defined as health-related quality of life and was used as a utility in the decision tree. The probabilities associated with each case were obtained by literature review, and health-related quality of life was evaluated by a questionnaire completed by 25 pediatric orthopedic experts. Our decision analysis model favored temporary hemiepiphysiodesis using a tension band plate over temporary hemiepiphysiodesis using percutaneous screws or stapling, with utilities of 0.969, 0.957, and 0.962, respectively. Oneway sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was better than temporary hemiepiphysiodesis using percutaneous screws, when the overall complication rate of hemiepiphysiodesis using a tension band plate was lower than 15.7%. Two-way sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was more beneficial than temporary hemiepiphysiodesis using percutaneous screws. [ABSTRACT FROM AUTHOR]

Study Design. Measurement of radiation dose from C-arm fluoroscopy during a simulated intraoperative use in spine surgery. Objective. To assess how the radiation dose is affected by changes in the types of thyroid shields used and by the arrangements or ways in which they are worn during the intraoperative use of C-arm fluoroscopy. Summary of Background Data. Although the danger to the thyroid from exposure to radiation is well known, there are no guidelines for the proper use of thyroid shields. Methods. Two photoluminescence dosimeters were used to measure the dose of scattered radiation arriving at the location of the thyroid in a whole-body phantom in the position of the surgeon. On an operating table beside this setup was an anthropomorphic chest phantom representing a patient for which treatment with C-arm fluoroscopy was simulated. Radiation doses were measured using 3 different arrangements of the thyroid shield: worn tightly, worn loosely, and worn loosely with a bismuth masking reagent. The same tests were performed using 2 kinds of thyroid shield: lead and lead-equivalent. Results. For the lead-shield group, radiation doses were measured in 3 arrangements; worn tightly, worn loosely, and worn loosely with a bismuth masking reagent, for which the results were 1.91 ± 0.13, 2.35 ± 0.22, and 1.86 ± 0.13 µSv/min, respectively. Wearing the shield tight against the throat and wearing it loose with a bismuth masking reagent led to lower radiation exposure levels than by simply wearing the shield loosely (P ≤ 0.001). For the lead-equivalent shield group, doses were measured for the same 3 arrangements, for which the results were 1.79 ± 0.12, 1.82 ±0.11, and 1.74 ± 0.12 µSv/min. Lower scattered radiation doses were delivered to the thyroid in the lead-equivalent thyroid shield group compared with the lead thyroid shield group (P ≤ 0.001). The unshielded thyroid group received a radiation dose of 16.32 ± 0.48 µSv/min. Conclusion. The use of some form of thyroid shield is essential during the use of C-arm fluoroscopy. It was found that the best way to reduce scattered radiation exposure to the thyroid was wearing the thyroid shield tightly or wearing it loosely in combination with a bismuth masking reagent. [ABSTRACT FROM AUTHOR]

Background: This study was performed to investigate the usefulness of clinical pathway (CP) using an electronic medical record (EMR) in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus, by analyzing the length of hospital stay, hospital cost and satisfaction of the medical teams. Methods: This before and after comparative study included consecutive children who underwent closed pinning for supracondylar fracture of the humerus since 2009. The pre-CP group consists of 90 patients with the mean age of 5.7 years, and the post-CP group consists of 32 patients with the mean age of 6.2 years. Multidisciplinary work-team developed CP using an EMR system in March 2011. The length of hospital stay was the primary outcome variable, and hospital cost and medical team's satisfaction score were secondary outcome variables. The non-inferiority test was used to demonstrate the efficiency of the pathway. Results: The length of hospital stay decreased from 2.9 ± 0.7 days to 2.4 ± 0.7 days by 15.0%, after the implementation of CP, and the lower bound of the 95% CI of the difference (0.14 day) was within the non-inferiority margin of -0.3 days. The hospital cost decreased from 1162.2 ± 236.7 US$ to 1139.8 ± 291.1 US$ by 1.9% and the lower bound of the 95% CI of the difference was -81.3 US$, which did not exceed the non-inferiority margin of -116.2 US$. Therefore, the post-CP group was not inferior compared with the pre-CP group in term of the length of hospital stay and total hospital cost. There was significant increase in the satisfaction score for doctors after implementation of CP (p < 0.001), but, no change in the satisfaction score for nursing staffs (p = 0.793). Conclusions: The development and implementation of CP, using an EMR, in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus enhances the treatment efficiency by streamlining the treatment process with no increases of the length of the hospital stay and total hospital costs. [ABSTRACT FROM AUTHOR]

Background: The relationship between torsional bony deformities and rotational gait parameters has not been sufficiently investigated. This study was to investigate the degree of contribution of torsional bony deformities to rotational gait parameters in patients with diplegic cerebral palsy (CP). Methods: Thirty three legs from 33 consecutive ambulatory patients (average age 9.5 years, SD 6.9 years; 20 males and 13 females) with diplegic CP who underwent preoperative three dimensional gait analysis, foot radiographs, and computed tomography (CT) were included. Adjusted foot progression angle (FPA) was retrieved from gait analysis by correcting pelvic rotation from conventional FPA, which represented the rotational gait deviation of the lower extremity from the tip of the femoral head to the foot. Correlations between rotational gait parameters (FPA, adjusted FPA, average pelvic rotation, average hip rotation, and average knee rotation) and radiologic measurements (acetabular version, femoral anteversion, knee torsion, tibial torsion, and anteroposteriortalo-first metatarsal angle) were analyzed. Multiple regression analysis was performed to identify significant contributing radiographic measurements to adjusted FPA. Results: Adjusted FPA was significantly correlated with FPA (r=0.837, p<0.001), contralateral FPA (r=0.492, p=0.004), pelvic rotation during gait (r=-0.489, p=0.004), knee rotation during gait (r=0.376, p=0.031), and femoral anteversion (r=0.350, p=0.046). In multiple regression analysis, femoral anteversion (p=0.026) and tibial torsion (p=0.034) were found to be the significant contributing structural deformities to the adjusted FPA (R2=0.247). Conclusions: Femoral anteversion and tibial torsion were found to be the significant structural deformities that could affect adjusted FPA in patients with diplegic CP. Femoral anteversion and tibial torsion could explain only 24.7% of adjusted FPA. [ABSTRACT FROM AUTHOR]

Background: Craniofacial deformity is one of the main features of congenital muscular torticollis. The purposes of this study were to quantify craniofacial deformity and its postsurgical change in patients with congenital muscular torticollis and to analyze this change with reference to the age at surgery. Methods: Eighty patients with congenital muscular torticollis who had successful surgical release of the sternocleidomastoid muscle and had preoperative and follow-up cephalometric evaluation were studied. The craniofacial deformity was evaluated in two aspects: curvature and asymmetry. Postsurgical changes of craniofacial deformity were analyzed in all patients. Two groups of patients were identified: Group 1, which consisted of patients who had surgery before five years of age; and Group 2, which consisted of patients who had surgery at or after five years of age. Preoperative deformity parameters and the postsurgical changes were compared between Groups 1 and 2. Finally, postsurgical changes in the first and second year postoperatively were compared in forty-two patients for whom cephalometric radiographs were made at both the first and second-year follow-up visits. Results: All of the cephalometric parameters improved significantly after surgical release of the sternocleidomastoid muscle (p <0.001). The preoperative craniofacial asymmetry parameters, such as transverse calvarial asymmetry and transverse skull-base asymmetry, were significantly more severe in Group 1 than in Group 2 (p = 0.018 in both), and these parameters improved significantly more in Group 1 than in Group 2 postoperatively (p = 0.029 and 0.003, respectively). No significant difference between Groups 1 and 2 was found in postsurgical changes of craniofacial curvature and mastoid-process length ratio. The improvements were significantly larger in the first year than they were in the second year in all parameters except mastoid-process length ratio. Conclusion: Cephalometry quantitatively showed improvement in the craniofacial deformity after surgical release of the sternocleidomastoid muscle. The results of this series were better when surgery was performed before the patient reached five years of age. More postsurgical change can be expected during the first year postoperatively than during the second year. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The choice of modalities for thromboprophylaxis after total joint arthroplasty is controversial. To address this issue, an evidence-based review of previous studies was performed. The characteristics of the studies selected for review can affect the final conclusion of an evidence-based review. One such characteristic, financial conflict of interest related to medical research, is a widespread concern. The purpose of the present study was to determine what proportion of studies on thromboprophylaxis after total joint arthroplasty were sponsored by industry and whether the assessments of thromboprophylaxis after total joint arthroplasty were associated with industry support. Methods: We searched PubMed for prospective, original, English-language studies, published from 2004 to 2010, on thromboprophylaxis after total joint arthroplasty. The funding sources of the articles were reviewed, and qualitative conclusions regarding the modality of interest for thromboprophylaxis after total joint arthroplasty were classified as being favorable, neutral, or unfavorable. Results: Seventy-one eligible articles were identified; fifty-two were funded by industry, and fourteen were not. The other five studies did not include information about the funding source. A significant association was observed between the funding source and qualitative conclusions (p = 0.033). Only two (3.8%) of the fifty-two industry-sponsored studies had unfavorable conclusions, whereas three (21.4%) of the fourteen non-industry-sponsored studies indicated that, depending on the clinical scenario, the modality examined was neither effective nor safe. Conclusions: Most studies on thromboprophylaxis after total joint arthroplasty are sponsored by industry. Moreover, the qualitative conclusions in those studies are favorable to the use of the sponsored prophylactic agent. [ABSTRACT FROM AUTHOR]

Background: Several radiologic parameters have been used to qualify an acetabular coverage in studies determining whether an association exists between acetabular dysplasia and osteoarthritis of hip. However, it is not known which parameter is optimum for these epidemiologic studies. We evaluate the reliability, validity, and robustness of the radiologic parameters of acetabular coverage used in these studies. Methods: Center-edge angle (CEA), acetabular depth (AD), acetabular angle (AA), acetabular roof obliquity (ARO), and roof angle (RA) were evaluated. The components of intra- and interobserver reliability were tested. The correlations between each parameter were used to depict convergent validity. The robustness of the parameters to different projection (urogram), different definitions of the lateral acetabular margin, and a differing pelvic tilt were evaluated. Results: The intra- and interobserver reliabilities of CEA, AD and AA ranged from 0.777 to 0.925. The CEA, AD and AA showed acceptable validity in the correlation. The AD on the urograms was 22.0% higher than those on the standing hip radiographs ( P < 0.001). When the osteophyte was included in the definition of lateral acetabular margin, the CEA and AD increased significantly ( P < 0.001). In simulating pelvic tilting, the AD increased significantly with the anterior pelvic tilt ( P < 0.001). The ARO and RA showed poor clinical relevance. Conclusion: When measuring acetabular dysplasia, the AD is unsuitable for use, because it is not robust to different projection of beam and different pelvic tilts. Furthermore, one should consider that the CEA and AA are significantly influenced by different definitions of lateral acetabular margin. [ABSTRACT FROM AUTHOR]

Background: This study was undertaken to determine the validity and reliability of the physical examination tests commonly used to measure hip flexion contracture in patients with cerebral palsy who are able to walk. Methods: Thirty-six consecutive patients (twenty-two male and fourteen female patients), with a mean age (and standard deviation) of 9.8 ± 3.9 years, who had cerebral palsy (level I, II, or Ill on the Gross Motor Function Classification System) and thirty-seven children without cerebral palsy (nineteen male and eighteen female subjects), with a mean age of 10.0 ± 3.0 years, were enrolled prospectively for this study. Hip flexion contracture was determined by three physical examination tests: the Thomas test, the prone hip extension test (the Staheli test), and the hamstring shift test. Three-dimensional gait analysis was performed in all subjects. The interobserver reliabilities of the three physical examination tests were determined with use of three observers. Convergent validity was assessed by evaluating the relationships between the findings on physical examination and kinematic and kinetic gait variables (maximum hip extension during stance and hip flexor index) and three-dimensional modeled psoas lengths. Results: The Thomas test showed the highest intraclass correlation coefficient (0.501 in patients and 0.207 in controls) and the smallest mean absolute difference (5.8° in patients and 1.2° in controls). The Staheli test was found to be the most valid method in the patient group (r = 0.568 with hip flexor index), whereas the Thomas test was the most valid in the control group (r = 0.526 with maximum hip extension in stance, and r = 0.532 with the hip flexor index). The hamstring shift test had the lowest intraclass correlation coefficient and the lowest convergent validity. Conclusions: While the Thomas test showed the highest intraclass correlation coefficient and the smallest mean absolute difference, the Staheli test was the most valid method for detecting hip flexion contractures in patients with cerebral palsy. Although the Staheli test cannot be used for intraoperative assessment, we recommend that this test be included in preoperative physical examinations to determine the role of a hip flexion contracture in the abnormal gait of patients with cerebral palsy. [ABSTRACT FROM AUTHOR]

The scattered radiation protector for mobile x-ray systems, Creative Valuable Protector-2, has been recently developed. However, there have been no studies investigating the effects of this device. We aim to investigate the effects of the scattered radiation protector on the equivalent doses from scattered radiation delivered to radiosensitive organs while simulating spine surgery using a C-arm fluoroscope. Chest and rando phantoms were used to simulate a patient and a surgeon in this study. The equivalent dose from scattered radiation to radiosensitive organs was measured in four different situations according to the use of the scattered radiation protector and the C-arm configuration. To compare the quality of the images with and without the scattered radiation protector, an acryl step phantom with five steps was used, and the contrast resolution of each step was calculated. The equivalent dose from the scattered radiation to the surgeon’s eye, thyroid, and gonad decreased significantly by using the scattered radiation protector for both the Posteroanterior (PA) (p  <  0.001) and Anteroposterior (AP) (p  <  0.001) C-arm configurations. The installation of the scattered radiation protector also reduced the direct radiation dose to the chest phantom. A scattered map showed that scattered radiation doses decreased by approximately 50% for the PA configuration and 75% for the AP configuration by using the scattered radiation protector. Before and after installation of the scattered radiation protector, the contrast resolution of each adjacent step area was 0.025–0.404 and 0.216–0.421. The scattered radiation protector was effective in reducing not only the equivalent dose from scattered radiation to the surgeon’s radiosensitive organs, but also the direct radiation dose to the patient. This was all achieved without decreasing the quality of the C-arm fluoroscopic images. [ABSTRACT FROM AUTHOR]