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Breech presentation is one of the most important risk factors for developmental dysplasia of the hip, and all breech infants should be screened. The necessity of further follow-up of developmental dysplasia of the hip after normal clinical and sonographic screening is a controversial subject. The purpose of this study to identify the incidence of delayed dysplasia in breech infants after normal ultrasound screening and the necessity of further clinical and radiologic follow-up in these patients.We included the 292 breech babies (128 boys and 164 girls) who showed normal hip ultrasound screening results. To determine the incidence of delayed radiographic dysplasia, anteroposterior hip radiographs were taken between 12 and 24 months of age to measure the acetabular index (AI).The mean AI values were 22.8±3.4 in boys and 24.9±3.1 in girls. Applying the Tönnis criteria, 29 patients (9.9%) were considered to have delayed radiographic dysplasia (16 boys and 13 girls). No significant difference was found in any demographic variables between babies with and without delayed radiographic dysplasia. None of these 29 infants underwent any treatment for radiographic dysplasia. Applying Kuong's criteria to 292 infants, only 2 patients (0.7%) demonstrated radiographic dysplasia on the hip anteroposterior radiographs taken at 14 months.The incidence of radiographic dysplasia significantly varied depending on which criteria were applied. In order to find out more accurate incidence rates of delayed radiographic dysplasia, large-scale studies of the normative AI data for Korean infants are required.Prognostic Level III.

Supplemental Digital Content is available in the text., Background: Computed tomography (CT) provides benefits for 3-dimensional (3D) visualization of femur deformities. However, the potential adverse effects of radiation exposure have become a concern. Consequently, a biplanar imaging system EOS has been proposed to enable reconstruction of the 3D model of the femur. However, this system requires a calibrated apparatus, the cost of which is high, and the area occupied by it is substantial. The purpose of this study was to develop a mobile application that included a new method of 3D reconstruction of the femur from conventional radiographic images and to evaluate the validity and reliability of mobile the application when measuring femoral anteversion. Methods: The statistical shape model, graph-cut algorithm, and iterative Perspective-n-Point algorithm were utilized to develop the application. The anteroposterior and lateral images of a femur can be input using the embedded camera or by file transfer, and the touch interface aids accurate contouring of the femur. Regarding validation, the CT scans and conventional radiographic images of 36 patients with cerebral palsy were used. To evaluate concurrent validity, the femoral anteversion measurements on the images reconstructed from the mobile application were compared with those from the 3D CT images. Three clinicians assessed interobserver reliability. Results: The mobile application, which reconstructs the 3D image from conventional radiographs, was successfully developed. Regarding concurrent validity, the correlation coefficient between femoral anteversion measured using 3D CT and the mobile application was 0.968 (P

Introduction: Identifying risk factors associated with developmental dysplasia of the hip (DDH) is essential for early diagnosis and treatment. Breech presentation is a major DDH risk factor, possibly because of crowding of the fetus within the uterus. In multifetal pregnancy, fetuses are generally smaller than singletons, which may obscure the effect of breech presentation on fetal hips. Only a few studies have investigated the occurrence of DDH in multifetal pregnancies. In this study, we aimed to evaluate whether the breech presentation is a major risk factor of DDH in twin pregnancies. Methods: This retrospective study included 491 consecutive live births (after 23+0 weeks gestation) delivered through cesarean section with at least 1 baby with noncephalic presentation in single or twin pregnancies from April 2013 to October 2018. We analyzed the incidence of DDH and its associated factors, including sex, breech, and multifetal pregnancy, with a generalized linear mixed model. Results: The incidence of DDH was 12.5% in singleton with breech presentation, 9.8% in twin-breech presentation, and 0.7% in twin-cephalic presentation. Multivariate analysis showed that singleton-breech presentation (P=0.003), twin-breech presentation (P=0.003), and female sex (P=0.008) were independent risk factors for DDH. Conclusion: Breech presentation is an independent risk factor for DDH in twin pregnancies, although twin pregnancy itself is not an independent risk factor for DDH.

BACKGROUND This study investigated the effect of screw configuration on the rate of correction of coronal angular deformity of the knee joint in children who underwent guided growth using the tension-band plate. METHODS Consecutive patients (76 patients with 154 physes; mean age: 11.8±2.2 y) who underwent guided growth using the tension-band plate for coronal angular deformity (genu varum or genu valgum) were included. The mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and screw angle were measured from the teleroentgenograms of preoperative and postoperative periodic follow-up visits. RESULTS The mean initial screw angle and the mean rate of correction were 16.7±10.5 degrees and 6.5±5.3 degrees per year, respectively. The rate of correction was significantly affected by age at surgery, sex, physis treated, severity of deformity, and rate of change in screw angle (all P

Purpose To examine the efficacy, safety, and clinical outcomes of distraction osteogenesis through the physis (PDO) or through subphyseal osteotomy (SPDO) in patients with atrophic-type congenital pseudarthrosis of tibia with proximal tibial dysplasia. Methods To validate the efficacy and safety of PDO and SPDO, radiographic and clinical parameters were compared between 5 patients who underwent proximal tibial metaphyseal or metadiaphyseal lengthening as a control (group 1) and 7 patients who underwent PDO or SPDO (group 2). Postoperative complication was also compared between the groups. Results A significant difference in terms of healing index (group 1, 83.3±24.7 d/cm; group 2, 35.0±11.1 d/cm; P=0.001) and percentage increase (11.0%±3.7% vs. 23.1%±10.5%, P=0.034) was observed between the 2 groups. According to the Paley classification, group 1 included 1 "problems" case and 3 "obstacles" cases, whereas group 2 included 2 "problems" cases and 1 "obstacles" case. According to the Lascombes classification, group 1 included 2 grade IIIb cases and 3 grade IV cases, whereas group 2 included 6 grade I cases and 1 grade IIa case. Severe complications were significantly higher in group 1 compared with the group 2 (P=0.007). Conclusions This study demonstrated that PDO or SPDO can be effectively and safely performed for tibial lengthening in atrophic-type congenital pseudarthrosis of tibia patients with proximal tibial dysplasia. Level of evidence Level III.

Background Recurrence of equinus deformity after surgery is common in patients with cerebral palsy. This retrospective study was undertaken to estimate the recurrence rate of the equinus deformity after tendo-Achilles lengthening (TAL) in patients with cerebral palsy and to investigate the risk factors associated with the recurrence. Methods Two-hundred forty three ambulatory patients with cerebral palsy, who underwent TAL for equinus foot deformity since 1995, and had undergone a preoperative and postoperative 3-dimensional gait analysis, were included. Cox proportional hazards model was used to determine the significant contributing factor for the recurrence of equinus foot deformity. Results The mean patient age at surgery was 7.8±2.7 years and the mean follow-up duration was 8.1±3.4 years. Equinus deformity recurred in 22 of the 243 patients (9.1%) and the Kaplan-Meier survival estimate was shown to be 89.4% at 10 years not needing repeat surgery. According to the multivariate analysis using the Cox proportional hazard model, preoperative ankle dorsiflexion at initial contact (P=0.016) was the only significant factor for recurrence of equinus deformity after surgery. Age at surgery and the type of limb involvement were not associated with the recurrence (P=0.433 and 0.269). The cutoff values of preoperative gait kinematics between the nonrecurrence and recurrence groups were -19 degrees of ankle dorsiflexion at initial contact (P=0.018). Conclusions This study showed that the severity of preoperative equinus deformity was a risk factor associated with recurrence after TAL in patients with cerebral palsy. Therefore, surgeons should consider the recurrence and later revision surgery for the patients with severe equinus foot deformity. Level of evidence Therapeutic level III.

Background Percutaneous epiphysiodesis using transphyseal screws (PETS) has been used to manage leg length discrepancy (LLD) in growing children. The purposes of this study were to analyze effects of PETS on LLD, its associated complications, to determine optimal operation timing, and find ways of preventing complications. Patients and methods The data of 59 patients obtained up to screw removal or at skeletal maturity were retrospectively analyzed. Retrospective growth calculations were done using multiplier method. The efficacy of LLD correction was calculated, and the predicted segment length with the index operation was compared with the final measured length and final LLD was measured. The screw insertion angle in 3-dimension was calculated, and it was correlated with the efficacy. Complications associated with screw design and the techniques used were analyzed. Results The LLD correction efficacy averaged 75.5% (5.0 to 114.0) at the distal femur and 78.9% (11.0 to 111.0) at the proximal tibia. However, mean final LLD was 3.0 mm (range, -10.0 to 16.7 mm), presumably because operations were performed on average 1.3 years earlier than estimated by growth calculation. Three-dimensional screw insertion angle was positively correlated with LLD correction efficacy. Complications were closely related to the screw design and the implantation techniques. Conclusions PETS provides a minimally invasive and effective means of LLD correction. In view of its delayed effect, we recommend that PETS be performed at least 1 year earlier than estimated optimal epiphysiodesis timing. The careful selection of screw design and length and accurate screw placement are the keys to successful results. Level of evidence Level IV prognostic studies.

UNLABELLED Hereditary multiple exostoses (HME) patients frequently present with ankle valgus deformity and marked fibular shortening. Loss of the lateral buttress may cause translational talus instability (TTI) that manifests as ankle pain after physical exercise, medial clear space widening on plain radiographs, and gross translational movement of the talus within the mortise. Among 123 HME patients examined and/or surgically treated, 10 patients (14 ankles) with symptomatic TTI underwent fibular lengthening with osteochondroma excision. Twelve ankles of 9 patients were followed for >1 year after surgery. Total fibular length gain averaged 15.3 mm and distal migration of the distal fibular fragment averaged 5.5 mm. The mean medial clear space decreased from preoperative 6.7 mm to postlengthening 3.5 mm. Gross instability of the talus within the ankle mortise disappeared in all cases. AOFAS ankle-hindfoot score improved from preoperative 80.3 to 97.3 at the latest follow-up. The current study showed the fibular lengthening improved lateral ankle stability by providing lateral buttress on the talus and providing favorable short-term result by ameliorating exercise-induced ankle pain in TTI of HME. The authors carefully conclude that TTI is a rare but potentially disabling condition in HME patients, requiring special attention during follow-up of HME patients. LEVEL OF EVIDENCE Level IV.

BACKGROUND: The authors have performed valgus femoral osteotomy (VFO) with rotational and sagittal components for Legg-Calve-Perthes disease hips with hinge abduction. We analyzed skeletally mature patients to determine: (1) whether VFO improved hip function; (2) whether favorable radiographic remodeling of the hip occurred; and (3) whether any clinical or radiographic factors were associated with remodeling of femoral head deformity. METHODS: Thirty-one patients (31 hips, 25 boys and 6 girls) who underwent VFO between 1986 and 2007, and subsequently followed until skeletal maturity constituted the study cohort. The mean age at surgery was 9.4 years (range, 3.5 to 15 y) and the mean age at the most recent follow-up was 20.2 years (range, 14.6 to 28.3 y). Clinical outcomes were evaluated using Iowa Hip Scores and ranges of hip motion. Radiographic outcomes were assessed with respect to the radiographic indices for femoral head deformity and subluxation. Clinical and radiographic parameters were analyzed to find correlations with the femoral head remodeling (preoperative to final follow-up changes in deformity index). RESULTS: Iowa Hip Score improved from 71 (30 to 91) to 92 (76 to 100). Ranges of hip abduction, internal rotation, and external rotation increased. At last follow-up evaluations, mean Mose sphericity index of the femoral head was 4.2 mm (range, 0 to 13 mm) and femoral heads had 4 Stulberg type II, 21 type III, and 6 type IV deformity. Overall radiographic indices for femoral head deformity and subluxation did not change during follow-up period except decreased medial joint space, but greater amount of preoperative to final follow-up changes in deformity index was associated with younger age (

Background The efficacy of using botulinum toxin A injections in cerebral palsy (CP) is controversial. The financial conflict of interest related to medical research can affect the conclusion of an evidence-based review. This study was performed to determine as to what proportion of studies on botulinum toxin A injections in patients with CP was sponsored by the industry and whether the assessments of botulinum toxin injection in CP were associated with industry support. Methods Studies were identified with a search of the PubMed database (January 1991 to November 2011). All prospective, comparative, English language studies on the use of botulinum toxin A injections in patients with CP were included. A total of 374 articles were screened, 128 potentially eligible full articles were retrieved, and 66 studies met our inclusion criteria. The funding sources of the articles were reviewed, and qualitative conclusions regarding the effect of botulinum toxin A injection were classified as being either favorable, neutral, or unfavorable. Results Of 66 eligible articles, 28 were funded by the industry, and 25 were not. The other 13 studies did not include information on the funding source. A significant association was observed between the funding source and qualitative conclusions (P=0.042). Fifteen (53.6%) of the 28 industry-sponsored studies had favorable conclusions, whereas only 5 (20%) of the 25 non-industry-sponsored studies had favorable conclusions. Conclusions About half of studies on the effect of botulinum toxin A in CP were sponsored by the industry. This systematic review revealed that the qualitative conclusions in those studies are more favorable to the use of the botulinum toxin A than the non-industry-sponsored studies. Clinicians should be aware of an industry-related conflict of interest regarding reports on the efficacy of botulinum toxin A injections in patients with CP. Level of evidence Level II-therapeutic study.

BACKGROUND Although previous studies have provided reference values for the lower limb alignment in children with physiological genu varum, those often have methodologic flaws, including problems with assumptions of statistical independence. In this study we intend to use appropriate statistical methods to determine reference values of the recovery of physiological genu varum by using a linear mixed model (LMM). METHODS The database of our institution was searched and teleroentgenograms of patients up to 5 years of age with clinical diagnosis of physiological genu varum were selected. The mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured from each radiograph. These measures were then incorporated in LMM. The reference values for mTFA, mLDFA, and mMPTA were calculated by LMMs with age, sex, and side of the limbs, as the fixed effects with each subject as random effects. RESULTS A total of 425 teleroentgenograms were evaluated from 161 patients with physiological genu varum. Age, sex, and limb side terms were found to be significant contributing factors to the measures. In the LMM, with the age as quadratic, mTFA was equal to -0.3-degree varus [95% confidence interval (CI), -5.9 to 5.3 degrees] at the age of 3 years. The mLDFA was equal to 87.8 degrees (95% CI, 82.8-92.8 degrees) at the age of 4.5 years. The mMPTA was equal to 88.8 degrees (95% CI, 80.4-97.2 degrees) at the age of 2.5 years. CONCLUSIONS An LMM fitted well to estimate the natural recovery of physiological genu varum. Age, sex, and side of the limbs were found to be significant factors in the estimation of mTFA, and age and side of limbs were significant in estimation of mLDFA and mMPTA. LEVEL OF EVIDENCE Level III-diagnostic study.

This study was performed to estimate the rate of angular correction after asymmetrical physeal suppression and analyze the factors that influence the rate of correction by using a linear mixed model application.A total of 175 physes (72 distal femoral, 70 proximal tibial, and 33 distal tibial) from 78 consecutive patients with valgus angular deformity of the lower limb who underwent asymmetrical physeal suppression were included. The anatomic lateral distal femoral angle, the anatomic lateral proximal tibial angle, and the anatomic lateral distal tibial angle were measured from the teleroentgenograms of the patients' preoperative visit and periodic follow-ups. The rate of angular correction was adjusted by multiple factors by using a linear mixed model with age, sex, and surgical method as the fixed effects and each subject as the random effect. The final model included the age-specific and surgical method-specific rate and sex-specific and surgical method-specific intercept. Multivariate analysis was performed for this model.In younger children (boys 14 y or younger and girls 12 y or younger), the rate of correction of valgus deformity at the distal femur, proximal tibia, and distal tibia was 0.71 degrees/month (8.5 degrees/y), 0.40 degrees/month (4.8 degrees/y), and 0.48 degrees/month (5.8 degrees/y), respectively. In older children, the rate of correction of valgus deformity at the distal femur, proximal tibia, and distal tibia was 0.39 degrees/month (4.7 degrees/y), 0.29 degrees/month (3.5 degrees/y), and 0.48 degrees/month (5.8 degrees/y), respectively. The rate of correction at the distal femur was significantly lower in older children (P = 0.025). The rate of angular correction at the proximal tibia was significantly faster in the screw group than in the staple group (P = 0.046).Asymmetrical physeal suppression with staples, percutaneous transphyseal screws, and permanent method all are effective methods for treating valgus deformity in growing children. When we treat valgus deformity in growing children, we should take into consideration the fact that the rate of correction at the distal femur is lower in older children, and that at the proximal tibia is faster in the screw group.Therapeutic level III.

BACKGROUND The pediatric outcomes data collection instrument (PODCI) was originally developed to carry out a functional assessment of children and adolescents (including patients with cerebral palsy), focusing on musculoskeletal health. Validated questionnaires are important for assessing the functional outcome of cerebral palsy, and are meant to have unidimensionality, proper item gap, no ceiling and floor effects, and no item redundancy. The advances in health measurements have led to the application of Rasch analysis to assess questionnaires. This study evaluated PODCI in patients with cerebral palsy using Rasch analyses. METHODS The study included a total of 720 patients with gross motor function classification system level I to III, 192 with unilateral involvement and 528 with bilateral involvement. Rasch analysis was performed to obtain information on (1) the information weight fit statistic to assess the unidimensionality and redundancy of the items in each domain; (2) average item calibration to detect the item separation; and (3) item map to evaluate the ceiling and floor effects. RESULTS The PODCI worked best in the sports/physical function domain. In information weight fit statistics, there were 4 items violating unidimensionality, which included "putting on his/her coat" in transfer/basic mobility and "getting together and do things with friends" in sports/physical function. There were 4 items with item redundancy. Inadequate item separation was observed in the transfer/basic mobility domain. A ceiling effect was found in all domains, except for the sports/physical function. CONCLUSIONS The sports/physical function domain in PODCI generally satisfies the requirements of Rasch item response theory and is an appropriate measure of the function in cerebral palsy. Although some individual items do not fit well, the PODCI can be improved by eliminating the redundant items and by adding more difficult tasks to fill in the gaps. LEVEL OF EVIDENCE Level II.

Arthrogryposis-Renal dysfunction-Cholestasis (ARC) syndrome (MIM♯208085) is a rare multisystem disorder, which involves the kidney, liver, skin, and central nervous and musculoskeletal systems. It is inherited as an autosomal-recessive trait, associated with germ-line mutations in the VPS33B gene. In this study, the authors reviewed the orthopaedic manifestations of ARC syndrome.Ten patients diagnosed as having ARC syndrome were the subjects of this study. ARC syndrome was confirmed by mutation analysis in 8 of the 10 patients. Medical records and radiographs were retrospectively reviewed with a focus on musculoskeletal manifestations.Seven patients either expired at 4 to 19 months of age or were presumed to have expired. The remaining 3 patients remained alive at the time of writing this manuscript and were aged from 7 to 23 months. All patients showed musculoskeletal symptoms and/or signs, which included vertical talus (7 feet, 4 patients), pes calcaneovalgus (4 feet, 3 patients), hip dislocation (6 hips, 3 patients), pathologic fractures (5 fractures in 5 patients), and rigid kyphosis (2 patients). No surgical intervention was performed. Orthopaedic treatments, other than fracture management, were abandoned soon after diagnoses were made.ARC syndrome should be included in the differential diagnosis of arthrogryposis. As there is no specific effective treatment for renal dysfunction and cholestasis, orthopaedic intervention should be postponed until long-term survival is expected, though this is unlikely.Level IV, diagnostic studies, case series.

The aim of this study was to compare the outcomes of angular deformity correction by hemiepiphyseal stapling versus percutaneous hemiepiphysiodesis using transphyseal screw in growing children.Forty-three physes in 19 patients underwent hemiepiphyseal stapling, and 37 physes in 23 patients underwent percutaneous transphyseal screw placement. All cases were followed up to skeletal maturity or for more than 1 year after hardware removal. Amounts and rates of angular deformity correction, physeal behaviors after hardware removal, and postoperative courses were compared between the 2 groups.The goal of angular correction was achieved in all except 2 patients, who reached skeletal maturity precociously. The mean rates of angular correction were not significantly different between the 2 groups, in both distal femur and proximal tibia. Hardware was removed before skeletal maturity from 56 physes. Angular change remained within 3 degrees for 43 physes (76.8%) at more than 1 year postoperatively, and the rebound phenomenon was observed in 12 (21.4%). No significant difference was observed between the 2 groups in terms of physeal behavior after hardware removal. Patients in the screw group were administered less postoperative pain medication, had shorter hospital stays, and smaller operation scars. In the stapling group, 1 case was complicated due to an extruded staple, and another case experienced premature physeal arrest at 1.5 years postoperatively. One case in the screw group experienced correction failure, probably because of a technical error during screw placement.Hemiepiphysiodesis using percutaneous transphyseal screw is as effective as hemiepiphyseal stapling in terms of angular deformity correction. Furthermore, hemiepiphysiodesis using transphyseal screw has the advantage of being a minimally invasive procedure, and in this series, did not cause permanent physeal arrest.Level III.

Background This study was performed to identify the issues of concern of parents of patients with cerebral palsy before single event multilevel surgery (SEMS). Methods The parental concerns of 64 patients [34 males, 30 females, mean age 15 y and 5 mo (SD 8 y and 10 mo)] with cerebral palsy were obtained using a questionnaire preoperatively. The issues of parental concern were evaluated using 59 items specifically designed for this study. The individual items were scored using a 5-point Likert scale (1 to 5). Results The top 5 issues of concern were as follows: postoperative rehabilitation, duration of rehabilitation, immediate postoperative pain, general anesthesia, and medical cost. Sporting activities and poor compliance to wearing orthosis were included in the top 5 issues of parental concern in patients with unilateral involvement. The overall parental concern in patients with unilateral involvement was lower than that in bilateral involvement (P=0.054). Parents of younger patients showed significantly higher concern score than those of older patients (P=0.020). There was no significant difference in the overall concern score between the parents of patients scheduled for bony procedures and those of patients scheduled for soft tissue procedures (P=0.298). Multiple regression analysis revealed the patient's age (P=0.018) and responding parent (father vs. mother, P=0.025) to be the factors that significantly affected the overall concern score (adjusted R(2)=0.281). Conclusions An understanding of the issues of concern will enhance communication between physicians and parents, which would assist in preoperative discussion. Level of evidence Diagnostic level II.

The purpose of this study was to analyze parent satisfaction and factors affecting that satisfaction with single-event multilevel surgery outcomes in ambulatory children with cerebral palsy.Two hundred seventy-nine ambulatory patients with cerebral palsy were enrolled in this study. Parental satisfaction after surgery was evaluated using a visual analog scale (0-10), and the explanatory variables were collected by chart review.Overall mean (SD) satisfaction after surgery was 7.9 (2.0), with mean follow-up of 6.6 years. The parents of patients classified as Gross Motor Function Classification System (GMFCS) level I cerebral palsy were more satisfied than parents of patients classified as GMFCS level II or III cerebral palsy (P = 0.029). Surgical satisfaction was higher for unilaterally involved patients than for bilaterally involved ones (P0.001). Multiple regression revealed predictors of satisfaction to be preoperative GMFCS level, diagnosis, age at surgery, and duration of follow-up.We believe that this data can be used to help predict the level of parental satisfaction when planning single-event multilevel surgery in ambulatory children with cerebral palsy.Level II-Prognostic studies (investigating the effect of patient characteristic on the outcome of disease).

Background Angular deformity around the knee joint in patients with multiple epiphyseal dysplasia (MED) causes alteration in knee biomechanics as well as cosmetic problem. We report angular correction by hemiepiphyseal stapling (HES) and physeal behavior after stapling removal in MED patients. Methods In 17 knees of 9 MED patients, 16 distal femoral and 8 proximal tibial physes were stapled. Age at operation ranged from 8.2 to 13.9 years. Thirteen knees were in valgus alignment and 3 in varus and were followed up for an average of 3.9 years. Angular deformity change was evaluated by the anatomical lateral distal femoral angle or anatomical medial proximal tibial angle. Mechanical axis deviation was defined as the percentage ratio of distance from the knee joint center to mechanical axis divided by half the width of the tibial plateau. Results Amount of angular correction by HES at the distal femur was 15.3 +/- 6.4 degrees for an average of 17.4 months, and at the proximal tibia, 8.6 +/- 2.0 degrees for an average of 13.4 months. Twelve distal femoral physes remained stationary (angular change 3 degrees) after staple removal, whereas 5 proximal tibial physes remained stationary, 2 rebounded, and 1 was progressive. Neither hardware problems nor clinical complications other than overcorrection or undercorrection were encountered. At the latest follow-up, mechanical axis deviation remained within +/-50% in 14 of 17 knees. The remaining 3 knees failed because of premature closure of the distal femoral physis, causing undercorrection of the deformity, insufficient rebound of an overcorrected knee, or progressive angular change after staple removal. Conclusions Hemiepiphyseal stapling is effective for angular correction in MED with minimal surgical insult. However, as physeal behavior after staple removal is rather unpredictable, overcorrection over zone 1 should be avoided, and close monitoring is mandatory until skeletal maturity.

Background Some patients with Perthes disease develop abnormal gait in the transverse plane, that is, out-toeing or in-toeing. Considering that this phenomenon occurs mainly in patients who presented late without previous treatment or failed in the containment treatment, we postulated that the deformed femoral head and its impingement to the acetabulum may play an important role in the pathomechanism of this abnormal gait. Methods Three-dimensional computed tomography (CT) and gait analysis were performed for 9 patients with late-presenting unilateral Perthes disease, who recently developed out-toeing (n = 5) or in-toeing (n = 4) gaits without torsional problems or foot deformities. Deformity of the femoral head was investigated, with special attention to the location and size of the femoral "hump." Kinematic gait data were used to analyze the difference in the impinging pattern of the hip joint between the 2 opposite groups of patients. The gait parameters evaluated were foot progression angle, hip rotation, and pelvis rotation in the transverse plane; hip flexion and extension in the sagittal plane; hip adduction and abduction in the coronal plane. Results In the 5 out-toeing patients, all affected hips had anteriorly deviated femoral hump, and they were externally rotated in the CT gantry with the hump facing the anterolateral part of the hip joint. On the other hand, all affected hips of the 4 in-toeing patients had laterally deviated hump, and they were internally rotated in the CT gantry with the hump facing the anterolateral part of the hip joint. Gait analysis showed abnormal hip rotation and compensatory pelvis rotation. Maximal flexion was decreased in all out-toeing hips. Unintentional adduction was observed in all in-toeing hips. Conclusions The results suggest that out-toeing and in-toeing gaits are apparently caused by the compensatory rotation of the proximal femur to avoid impingement by placing the femoral hump to the relatively deficient anterolateral part of the hip joint.

Background Limited knee extension is a well-known sign in children with discoid meniscus, but its causative mechanism is controversial. The purpose of this study was to characterize discoid meniscus with this clinical manifestation with a focus on instability of the posterior segment and its morphologic features. Methods The authors retrospectively reviewed magnetic resonance imaging and intraoperative arthroscopic videos of 34 knees in 32 consecutive patients (age range, 4.5-15.0 years) who underwent arthroscopic treatment for symptomatic discoid lateral meniscus. Knees were classified into 2 groups, depending on the presence (n = 19) or absence (n = 15) of an extension block, which was defined as a limitation of knee extension by 10 degrees or more under general anesthesia. Meniscal instability in the posterior segment was determined based on arthroscopic findings, and its correlation with knee extension block was analyzed. Using magnetic resonance imaging, the thicknesses of anterior and posterior segments were measured to assess significance of the thickness differences by a presence of knee extension block and by the posterior segment instability. Results There were 13 knees with a stable posterior segment and 21 knees with an unstable posterior segment. Meniscal instability in the posterior segment was observed in the knees with a surface tear (n = 12), in a hypermobile posterior rim despite the absence of a surface tear (n = 5), and in knees with a freely movable posterior rim without posterior tibial attachment (n = 4). Knee extension block occurred exclusively in complete type menisci and was significantly correlated with meniscal instability in the posterior segment. Magnetic resonance imaging observations suggested that morphologic features characteristic of thick anterior and thin posterior segments were significantly associated with meniscal instability in the posterior segment. Clinically, knee extension block disappeared in all cases within 4 months of arthroscopic treatment. Conclusions A redundant anterior segment associated with meniscal instability in the posterior segment is likely to cause limited knee extension in children with discoid lateral meniscus. This correlation mandates that discoid menisci be thoroughly evaluated during arthroscopic treatment to identify any instability that might require stabilization.

The purpose of this study was to investigate the efficacy of oral alendronate for children with osteogenesis imperfecta. Nine boys and seven girls of average age 9.5 years were given oral alendronate for an average of 4 years. Fracture frequency decreased, and in more than half of the patients the ambulatory/mobility status improved. Bone mineral density improved significantly, and restoration of collapsed vertebral bodies was observed. Urinary excretion of calcium and a bone resorption marker decreased significantly. Iliac crest physis biopsy showed an expanded primary spongiosa area with numerous multinucleated cells. This study reveals that oral alendronate caused biochemical, radiologic, and histologic changes along with clinical improvement. Oral alendronate treatment, which is convenient for the school-age group, was found to be a tolerable and efficacious treatment for children with moderate or severe osteogenesis imperfecta.