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Background: Physical skeletal loading can affect the bone mineral density (BMD). This study investigated the association between BMD and dynamic foot pressure during gait. Methods: A total of 104 patients (mean age, 62.6 ± 12.4 years; 23 male and 81 female) who underwent dual x-ray absorptiometry and pedobarography were included. BMD values of the lumbar spine, femoral neck, and total femur were assessed. The mean and maximum pressures were measured at the hallux, lesser toes, 1st metatarsal head, 2nd and 3rd metatarsal heads, 4th and 5th metatarsal heads, midfoot, medial heel, and lateral heel. Multivariable regression analysis was performed to identify factors significantly associated with BMD. Results: The lumbar spine BMD was significantly associated with the mean pressure at the 4th and 5th metatarsal heads (p = 0.041, adjusted R2 of model = 0.081). The femoral neck BMD was significantly associated with the maximum pressure at the 2nd and 3rd metatarsal heads (p = 0.002, adjusted R2 = 0.213). The total femoral BMD also showed a significant association with the maximum pressure at the 2nd and 3rd metatarsal heads (p = 0.003, adjusted R2 = 0.360). Conclusions: Foot plantar pressure during gait was significantly associated with BMD, and could potentially be used to predict the presence of osteoporosis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [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: 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: 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: 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]

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]

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: 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: 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]