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Abstract Background The rotational change after using a flexible intramedullary (IM) nail for femoral shaft fractures has been a concern for many surgeons. Recently, a statistical shape model (SSM) was developed for the three-dimensional reconstruction of the femur from two-dimensional plain radiographs. In this study, we measured postoperative femoral anteversion (FAV) in patients diagnosed with femoral shaft fractures who were treated with flexible IM nails and investigated age-related changes in FAV using the SSM. Methods This study used radiographic data collected from six regional tertiary centers specializing in pediatric trauma in South Korea. Patients diagnosed with femoral shaft fractures between September 2002 and June 2020 and patients aged 20° was 32.74°, and the LMM showed that FAV decreased by 2.5° (p = 0.0001) with each 1-year increase from the time of initial trauma. Conclusions This study explored changes in FAV after femoral shaft fracture using a newly developed technology that allows 3D reconstruction from uncalibrated 2D images. There was a pattern of change on the rotation of the femur after initial fixation, with a 2.5° decrease of FAV per year.

Abstract Background Patient safety incidents lead to performance difficulties for nurses when providing nursing practice. This affects work-life balance and causes second and third-victimization. This study predicts factors affecting clinical nurses’ work-life balance due to patient safety incidents using classification and regression tree analysis techniques. Methods This study was a secondary analysis of data from a cohort research project, which used a descriptive survey for data collection. Participants comprised 372 nurses. Data were collected using SurveyMonkey, a mobile-based survey software solution, from January to September 2021. Data included the general characteristics of clinical nurses, second damage, second damage support, third damage, and work-life balance. The specific variables included in the analysis chosen through rigorous Lasso analysis form the foundation for predicting work-life balance. Variables with low explanatory power were excluded, thereafter, the variables selected by Lasso were analyzed with a classification and regression tree model to predict work-life balance. Results A regression tree was applied to predict work-life balance using seven variables—education level, marital status, position, physical distress, second-victim support, turnover intentions, and absenteeism (selected through Lasso analysis). After pruning, at tree size four, when turnover intentions were

Abstract Background The Gross Motor Function Classification System (GMFCS) is a widely used tool for assessing the mobility of people with Cerebral Palsy (CP). It classifies patients into different levels based on their gross motor function and its level is typically determined through visual evaluation by a trained expert. Although gait analysis is commonly used in CP research, the functional aspects of gait patterns has yet to be fully exploited. By utilizing the gait patterns to predict GMFCS, we can gain a more comprehensive understanding of how CP affects mobility and develop more effective interventions for CP patients. Result In this study, we propose a multivariate functional classification method to examine the relationship between kinematic gait measures and GMFCS levels in both normal individuals and CP patients with varying GMFCS levels. A sparse linear functional discrimination framework is utilized to achieve an interpretable prediction model. The method is generalized to handle multivariate functional data and multi-class classification. Our method offers competitive or improved prediction accuracy compared to state-of-the-art functional classification approaches and provides interpretable discriminant functions that can characterize the kinesiological progression of gait corresponding to higher GMFCS levels. Conclusion We generalize the sparse functional linear discrimination framework to achieve interpretable classification of GMFCS levels using kinematic gait measures. The findings of this research will aid clinicians in diagnosing CP and assigning appropriate GMFCS levels in a more consistent, systematic, and scientifically supported manner.

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 Background Gait deviation and associated torsional problems are common in patients with cerebral palsy (CP). Although femoral anteversion in CP has been extensively reviewed in previous studies, only a few studies have focused on tibial torsion. Therefore, this study aimed to evaluate tibial torsion in patients with CP and investigate the affecting factors. Methods Consecutive patients with cerebral palsy who underwent 3-dimensional computed tomography for the assessment of rotational profiles were reviewed. Femoral anteversion and tibial torsion were measured, and the demographic characteristics of the patients were recorded. A linear mixed model was implemented to overcome the retrospective nature of the study. Results After the implementation of inclusion and exclusion criteria, 472 patients were enrolled for this study. With age, external tibial torsion increased, while femoral anteversion decreased. The factors affecting external tibial torsion were increased femoral anteversion (p = 0.0057), increased age (p

Abstract Background The purpose of this study was to identify differences in caregiver responses to Korean-language and English-language versions of the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire. Methods Patient data were acquired from the Cerebral Palsy Hip Outcomes Project database, which was established to run a large international multicenter prospective cohort study of the outcomes of hip interventions in cerebral palsy. Thirty-three children whose caregivers had completed the Korean version of CPCHILD were matched by propensity scoring with 33 children whose parents completed the English version. Matching was performed on the basis of 12 covariates: age, gender, gross motor function classification system level, migration percentage of right and hip, seizure status, feeding method, tracheostomy status, pelvic obliquity, spinal deformity, parental report of hip pain and contracture interfering with care. Results There were no significant differences in CPCHILD scores for section 4 (Communication and Social Interaction), and section 5 (Health) between two groups. Korean-language CPCHILD scores were significantly lower than English-language CPCHILD scores for section 1 (Personal Care/Activities of Daily Living), section 2 (Positioning, Transferring and Mobility), section 3 (Comfort and Emotions) and section 6 (Overall Quality of Life) as well as in terms of total score. Conclusions Cultural influences, and the community or social environment may impact the caregivers’ perception of the health-related quality of life of their children. Therefore, physicians should consider these differences when interpreting the study outcomes across different countries.

Abstract Background Analyzing radiographic changes of pes planovalgus(PV) deformity of cerebral palsy(CP) patients according to age and influencing factors. Methods CP patients with PV deformity younger than 18 years old who had undergone more than a year of follow-up with at least two standing foot radiographs were included. Anteroposterior and lateral talo-first metatarsal(talo-1stMT), talo-second metatarsal(talo-2ndMT), and hallux valgus(HV) angles were measured on the radiographs. The rate of progression was adjusted by multiple factors using the linear mixed model, with the Gross Motor Function Classification System(GMFCS) level as the fixed effect and age and each subject as random effects. Results Overall, 194 patients were enrolled in this study, and 1272 standing foot radiographs were evaluated. The AP talo-2ndMT angle progressed by 0.59° (p

Abstract Background In order to optimize the tenogenic differentiation of mesenchymal stem cells (MSCs), researchers should consider various factors. However, this requires testing numerous experimental settings, which is costly and time-consuming. We aimed to assess the differential effects of transforming growth factor beta-3 (TGF-β3) on the tenogenesis of tonsil-derived MSCs (T-MSCs) and bone marrow-derived MSCs (BM-MSCs) using response surface methodology (RSM). Methods Bone marrow and tonsillar tissue were collected from four patients; mononuclear cells were separated and treated with 5 or 10 ng/mL of TGF-β3. A full factorial experimental design with a categorical factor of 0 was employed to study the effect of tension based on T-MSCs. Eighty-four trials were fitted with RSM and then used to obtain mathematical prediction models. Results Exposure of T-MSCs and BM-MSCs to TGF-β3 increased the expression of scleraxis (SCX), tenomodulin (TNMD), decorin, collagen I, and tenascin C. Expression of most of these factors reached a maximum after 2–3 days of treatment. The model predicted that the values of the tenocyte lineage-related factors assessed would be significantly increased at 2.5 days of culture with 2.7 ng/mL of TGF-β3 for T-MSCs and at 2.3 days of culture regardless of TGF-β3 concentration for BM-MSCs. Conclusions This study demonstrated that the RSM prediction of the culture time necessary for the tenogenic differentiation of T-MSCs and BM-MSCs under TGF-β3 stimulation was similar to the experimentally determined time of peak expression of tenocyte-related mRNAs, suggesting the potential of using the RSM approach for optimization of the culture protocol for tenogenesis of MSCs.

Abstract Background Dega pelvic osteotomy is commonly performed procedure in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for hip displacement. However, there has been no study investigating the outcomes after Dega pelvic osteotomy using allograft in patients with CP. This study investigated the outcomes of Dega pelvic osteotomy using iliac crest allograft in CP with hip displacement and the factors affecting allograft incorporation. Methods This study included 110 patients (150 hips; mean age 8y7mo; 68 males, 42 females) who underwent hip reconstructive surgeries including Dega pelvic osteotomy using iliac crest allograft. To evaluate the time of allograft incorporation, Goldberg score was evaluated according to the follow-up period on all postoperative hip radiographs. The acetabular index, migration percentage, and neck-shaft angle were also measured on the preoperative and postoperative follow-up radiographs. Results The mean estimated time for allograft incorporation (Goldberg score ≥ 6) was 1.1 years postoperatively. All hips showed radiographic union at the final follow-up and there was no case of graft-related complications. Patients with Gross Motor Function Classification System (GMFCS) level V had 6.9 times higher risk of radiographic delayed union than those with GMFCS level III and IV. Acetabular index did not increase during the follow-up period (p = 0.316). Conclusions Dega pelvic osteotomy using iliac crest allograft was effective in correcting acetabular dysplasia, without graft-related complications in patients with CP. Furthermore, the correction of acetabular dysplasia remained stable during the follow-up period.

Category: Ankle, Hindfoot Introduction/Purpose: Varus limb malalignment results in an imbalance of force transmission to the knee joint, resulting in a concentrated load in the medial compartment. A varus knee correction may affect the ankle and subtalar joint, because the weight-bearing load on the lower extremity extends from the hip to the foot. A previous study suggested that the true mechanical axis of the lower limb should be calculated with a line from the center of the femoral head to the lowest point of the calcaneus, not to the center of the tibial plafond. Therefore, we performed this study to evaluate changes in the mechanical axis and weight- bearing line of the ankle after varus knee correction. Methods: Patients with a varus knee who were followed-up after they had undergone high tibial osteotomy (HTO) or total knee replacement arthroplasty (TKA) at an age of >20 years, and who had undergone preoperative and postoperative scanogram were included in this study. The hip-knee-ankle (HKA) angle, mechanical axis, and weight-bearing line (line from the center of the femoral head to the lowest point of the calcaneus) were measured on the radiographs. The point at which the mechanical axis and weight-bearing line passed through the tibial plafond was the ankle joint axis point. The postoperative change in the ankle joint axis point on the mechanical axis and weight-bearing line according to the HKA angle correction was adjusted by multiple factors using a linear mixed model. Results: A total of 257 limbs from 198 patients were included in this study. The preoperative HKA was 7.3 ± 4.7° and corrected to 0.4 ± 3.8°. Although the ankle axis points on both axes moved laterally after HTO and TKA, the ankle joint axis of the weight- bearing line showed a significant larger lateral movement (22.5±35.7%) (Fig.) than that of the mechanical axis (15.7±16.0%) in terms of rate of change (p = 0.006). The ankle joint axis point on the weight-bearing line moved laterally by 0.9% per degree of postoperative HKA angle decrease (p < 0.001). The change in the ankle joint axis point on the mechanical axis was not statistically significant after HTO and TKA (p = 0.223). Conclusion: The mechanical axis and weight-bearing line of the ankle moved laterally after the varus knee correction. The ankle joint axis on the weight-bearing line moved laterally as the HKA angle decreased after the surgery, whereas the varus knee correction did not significantly affect the ankle joint axis on the mechanical axis. The varus knee correction might affect the subtalar joint as well as the ankle joint. Therefore, we believe that our findings warrant consideration in pre- and postoperative evaluations using the weight-bearing line of patients undergoing varus knee correction.

Abstract Background Concurrent prophylactic femoral varization osteotomy (FVO) for stable hips has been performed in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for the contralateral displaced hip. However, there is currently a lack of studies investigating the outcome after the prophylactic FVO in stable hip. This study investigated the outcomes after FVO in stable hips with CP and influencing factors. In addition, this study compared the outcomes with those after hip reconstructive surgery in the contralateral displaced hip. Methods This study included 119 CP patients with 224 hips (80 stable, 144 displaced) undergoing hip reconstructive surgery including FVO. Migration percentage (MP), neck-shaft angle (NSA), and head-shaft angle (HSA) were measured through preoperative and follow-up hip radiographs. All hips were divided into the stable (MP ≤ 33%) and displaced hip groups (MP > 33%) according to the preoperative radiographs, and the annual changes in the radiographic indices after FVO were analyzed. Results In stable hip group, MP did not significantly increase over time (p = 0.057) after prophylactic FVO. In displaced hip group, MP significantly increased over time (1.6%/year, p

Abstract Background Simultaneous motion of the knee and ankle joints is required for many activities including gait. We aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in the sagittal plane in cerebral palsy patients. Methods We included data from 55 limbs in 34 patients with spastic cerebral palsy. Patients were followed up after undergoing only distal hamstring lengthening with or without additional rectus femoris transfer. The patients’ mean age at the time of knee surgery was 11.2 ± 4.7 years, and the mean follow-up duration was 2.2 ± 1.5 years (range, 0.9–6.0 years). Pre- and postoperative kinematic variables that were extracted from three-dimensional gait analyses were then compared to assess changes in ankle motion after knee surgery. Outcome measures included ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, peak ankle dorsiflexion during swing, and dynamic range of motion of the ankle. Various sagittal plane knee kinematics were also measured and used to predict ankle kinematics. A linear mixed model was constructed to estimate changes in ankle motion after adjusting for multiple factors. Results Improvement in total range of motion of the knee resulted in improved motion of the ankle joint. We estimated that after knee surgery, ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, peak ankle dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4° (p = 0.016), 0.6° (p

Abstract Background We performed this study to investigate the influence of recombinant human growth hormone (rhGH) therapy on radiographic indices of the spine using propensity-matched analysis. Methods Patients with idiopathic short stature who had undergone both growth hormone therapy and whole-spine radiographs more than twice prior to 15 years of age were included in the patient group. Other patients who had undergone whole-spine radiographs more than twice prior to the same age during regular checkups for idiopathic scoliosis formed the control group. Propensity-matched analysis was performed to reduce the selection bias. The scoliosis Cobb angle, coronal balance, apical vertebral translation, apical rotation, and pelvic obliquity were measured from the radiographs taken at the periodic follow-ups. The rate of progression of the measurements was adjusted by multiple factors using a linear mixed model with sex as the fixed effect and age and each subject as the random effects. Results Using a propensity-matched analysis, 48 patients were finally included in both groups. The scoliosis Cobb angle increased by 1.0° (p

Category: Basic Sciences/Biologics Introduction/Purpose: Researchers should consider various potential factors that affect tenogenic differentiation of MSCs. Numerous experimental settings are associated with high cost and time. Response surface methodology (RSM), a component in the design of experiments (DOE), is gaining recognition as a powerful tool in optimizing conditions for the production of industrially important products such as chemicals and enzymes. The purpose of this study was to access the differential effects of transforming growth factor beta 3 (TGF-β3) on the tenogenesis of tonsil-derived mesenchymal stem cells (T-MSCs) and bone marrow-derived mesenchymal stem cells (BM-MSCs) using RSM. Methods: Bone marrow was collected from four patients (mean age: 79.0±2.2) and mononuclear cells were separated. The tonsillar tissues were collected from four patients (mean age: 7.6±0.6). After isolation of MSCs, they were treated with 5ng/ml and 10ng/ml of TGF-β3 with vehicle control. The full-factorial experimental design was employed to study the effect of tension based on T-MSCs. The design was composed of three levels being coded as -1, 0 and +1 and a total of 18 runs were carried out in duplicates to optimize the level of chosen variables, such as days and amount. A total of 84 trials were utilized and fitted with RSM; they were then used to obtain mathematical prediction models. Results: Exposure of TGF-β3 to T-MSCs and BM-MSCs resulted in an increase in the expression of SCX, TNMD, decorin, collagen I, and tenacin C. Most tenocyte lineage-related factors from T-MSCs and BM-MSCs presented a maximum increase in 2- 3 day treatment. Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced at 2.7 ng/mL of TGF-β3 (p < 0.001) on 2.5-day culture (p = 0.001). (Fig A) Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced on 2.3-day culture (p = 0.004) regardless of the concentration of TGF-β3. (Fig B) Conclusion: We demonstrated that tenocyte-like cells can be successfully differentiated from T-MSCs and BM-MSCs under TGF- β3 stimulation. This study demonstrated that T-MSCs and BM-MSCs in tenogenic stimulation with TGF-β3 have a similar tenogenic differentiation potential using RSM.

Category: Bunion Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p

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Category: Bunion, Midfoot/Forefoot Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p

Category: Ankle, Sports Introduction/Purpose: We hypothesized that the bony configuration of the ankle could also be associated with ankle stress radiographs, in addition to ligament injury of the ankle. Therefore, this study aimed to investigate the relationship between bone morphology and injured ligament on imaging studies and laxity on ankle stress radiographs in patients with lateral ankle instability. Methods: In total, 115 patients who had undergone ankle MRI, ankle radiography, and stress radiography were included. Distal tibial articular surface angle, bimalleolar tilt, medial and lateral malleolar relative length, medial malleolar slip angle, anterior inclination of the tibia, and fibular position were measured on ankle radiographs. Tibiotalar tilt angle and anterior translation of the talus were measured on ankle stress radiographs. Degree of ligament injury was evaluated on ankle MRIs. Multiple regression analysis was performed using the following independent variables: age, sex, and factors significantly associated with ankle stress view on univariate linear regression analysis. Results: Age (p = 0.041), sex (p = 0.014), degree of anterior talofibular ligament injury (p < 0.001), and bimalleolar tilt (p = 0.016) were correlated with tibiotalar tilt angle (Table). Younger patients demonstrated a larger tibiotalar tilt angle than older patients, and the angle decreased by 0.07° per year of age. Tibiotalar tilt angle in female patients was 2.2° larger than that in male patients. Fibular position and degree of posterior talofibular ligament injury were factors significantly related to anterior translation of the talus. Conclusion: Differences in patient characteristics might predispose ankle stress radiograph results. Comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side, in order to reduce the influence of patient factors.

Category: Ankle Introduction/Purpose: The gastrocnemius, a biarticular muscle that crosses the knee and ankle, acts as a knee flexor as well as an ankle plantar flexor. Although simultaneous motion of the knee and ankle joints is required for many activities including standing, running, swimming, and cycling, the change in ankle motion during gait has not been described in patients with cerebral palsy who underwent distal hamstring lengthening or distal hamstring lengthening with rectus femoris transfer. Therefore, we aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in cerebral palsy patients. Methods: The analysis included data regarding 55 limbs from 34 patients with spastic cerebral palsy, who were followed-up after they had undergone distal hamstring lengthening with or without additional rectus femoris transfer. Mean age of the patients at time of the knee surgery was 11.2 ± 4.7 years. Preoperative and postoperative kinematic variables that were extracted from three-dimensional gait analyses were compared to assess the change in ankle motion after surgery involving tendons around the knee. The postoperative 3D gait analysis was performed at a mean of 0.9 ± 1.3 years after the surgery. The outcome measures were relevant kinematics parameters including peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle. A linear mixed model was constructed to estimate the changes in ankle motion after adjusting for multiple factors. Results: We estimated that peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4º (p=0.016), 0.6º (p

Category: Ankle Introduction/Purpose: Although comparison to radiographic standards for ankle joint is critical for evaluation of syndemosis injuries, such standards are not well defined for children and adolescents. The purpose of this study was to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus and appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex. Methods: This study included 590 subjects (0 to 15 years), who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis were recorded (Fig 1). Tibiofibular overlap, tibiofibular clear space, medial clear space, talar tilt, talocrural angle, relative fibular width and fibular position were measured (Fig 2). A inter- and intrareliability test was conducted before the main measurements using intraclass correlation coefficients (ICC). To determine the timing of the ossification center of medial malleolus and appearance of tibial incisura, multinomial logistic regression was used. The generalized linear model was used to estimate the radiographic measurements by age and sex. The 100-quantiles were calculated to determine the normal value of the tibiofibular clear space, tibiofibular overlap and medial clear space. Results: All radiographic measurements showed good to excellent intraobserver(ICC, 0.603–0.934) and interobserver reliability(ICC, 0.704–0.972). The timing of ossification of medial malleolus and appearance of tibial incisura between boys and girls were not different. Tibiofibular clear space on mortise view, and medial clear space on AP and mortise view significantly decreased by age. Tibiofibular overlap on AP and mortise views, relative fibular width on AP view significantly increased by age. Talocrural angle, tibiofibular overlap on AP view, tibiofibular clear space on AP and mortise views, medial clear space on AP and mortise views and fibular position were significantly larger in boys than in girls. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on mortise view of both sides was < 50% in 98.1%, 99.3%, and 100% of patients, respectively. Conclusion: Tibiofibular clear space, tibiofibular overlap and medial clear space can be parameter to assess distal tibiofibular syndesmosis or deltoid ligament injury in skeletally immature patients. For these patients, the criteria of absolute radiographic values used in adults cannot be applied, but comparison of both sides could help physicians to predict the need for additional evaluations.

Category: Ankle Introduction/Purpose: Although previous studies have demonstrated the potential of conventional computed tomography (CT) as a screening tool for osteoporosis, the assessment correlation of BMD in those studies was limited to the spine. This study aimed to evaluate the reliability and validity of CT as a screening tool for osteoporosis and to estimate the correlation between central BMD and peripheral bone attenuation using lower extremity CT. Methods: In total, 292 patients who underwent a lower extremity, lumbar spine, or abdomen and pelvic CT scan within a 3- month interval of a dual-energy X-ray absorptiometry (DEXA) examination were included (Fig 1). Following reliability testing, bone attenuation of the L1, L2, L3, L4, femoral head, femoral neck, greater trochanter, distal femur, proximal tibia, distal tibia, and talus was measured by placing a circular region of interest on the central part of each bony region on a coronal CT image (Fig 2 and 3). Partial correlation was used to assess the correlation between CT and DEXA, after adjusting for age and body mass index. Results: In terms of reliability, all bone attenuation measurements, except the femoral neck, showed good to excellent interobserver reliability (intraclass correlation coefficients, 0.691–0.941). In terms of validity, bone attenuation of the L1 to L4, femoral neck, and greater trochanter on CT showed significant correlations with BMD of each area on DEXA (correlation coefficients, 0.399–0.613). Bone attenuation of the distal tibia and talus on CT showed significant correlations with BMD of all parts on DEXA (correlation coefficients, 0.493–0.581 for distal tibia, 0.396–0.579 for talus). Conclusion: Lower extremity CT is a useful screening tool for osteoporosis, and peripheral bone attenuation on lower extremity CT adequately reflects central BMD on DEXA.