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Purpose : This study evaluated the efficacy of the Ilizarov technique for the treatment of patients with congenital pseudoarthrosis of the tibia (CPT). Material and Methods : Twenty-two patients with CPT, who underwent osteosynthesis using the Ilizarov technique and were followed-up for more than 3 years, were enrolled in this study. The clinical and radiological data were reviewed to evaluate the outcomes of the Ilizarov technique. Results : The initial osteosynthesis was carried out successfully with the Ilizarov method at average age of 4.6 years. Twenty refractures occurred in 12 patients, who were also treated successfully using the Ilizarov method. Tibial lengthening (27 cases), medial tibial hemiepiphysiodesis (23 cases), distal tibiofibular synostosis (17 cases) were combined with a total of 42 Ilizarov osteosyntheses. After an average 8.1 years follow-up, the mean limb length discrepancy was 1.6 cm, and average anterior apex and valgus angulation of the tibial shaft were 6.3˚ and 7.3˚, respectively. The mean ankle alignment was valgus 1.9, and the mean range of motion of the ankle joint was 21˚ dorsiflexion and 33˚ plantar flexion. Conclusion : The Ilizarov technique combined with tibial lengthening, distal tibiofibular synostosis and/or medial tibial hemiepiphysiodesis is an effective procedure that can achieve bony union as well as a functional limb.

Purpose: The purpose of this study was to evaluate the safety and efficacy of intravenous patient-controlled analgesia (PCA) with fentanyl and ketorolac for postoperative pain management in patients with cerebral palsy. Materials and Methods: Sixty patients were categorized based on operation complexity into either a minor operation group or a major operation group, and then subdivided based on the analgesic methods used, i.e., intravenous PCA with fentanyl and ketorolac or intravenous pethidine injection. Pain intensity was assessed using the Wong-Baker's faces pain scale. Results: In the major operation group, patients that received PCA had significantly lower pain scores than those who received intravenous pethidine injection, while no significant differences in pain scores were observed in the minor operation group. Moreover, the side effects of these two analgesic methods did not differ significantly. Conclusion: Intravenous PCA with fentanyl and ketorolac is effective and safe for moderate to severe postoperative pain control in pediatric patients with cerebral palsy.

Purpose: To understand the relationship between the gait patterns in transverse plane and the transverse plane deformities. Materials and Methods: We evaluated the clinical, radiological, and three-dimensional gait analysis data of 152 spastic diplegics with transverse plane deformities. We define the transverse plane deformities as follows: 1) femoral anteversion , 2) thigh foot angle or , 3) severe foot deformities that could affect the foot progression angle. Results: We classified gait patterns of spastic diplegics into 6 groups on the base of pelvic compensation and foot progression angle, and divided anatomic characteristics into symmetric and asymmetric type. Among the gait patterns, pattern I-A (in-toeing with pelvic compensation) and II-A (in-toeing without pelvic compensation) were most prevalent. Femoral antetorsion was the most frequent torsional deformities, whereas valgus of foot was second most. Conclusion: We classified the gait patterns and analyzed the relationship between each gait pattern and types of torsional deformities.

Purpose: This study was performed to set up the normal kinematics and kinetics according to age in the Korean population. Materials and Methods: Normal adults and children without a previous history of musculoskeletal problems were enrolled in this study. According to the subjects' age, the normal volunteers were divided into 3 groups as follows: Group I; the children group (4-17), Group II; the young adult group (18-40) and Group III; the old adult group (41-). The linear indices and kinematics were measured using 5 CCD cameras while volunteers walked through a 9 m walkaway with a self-selected speed. The kinetics were measured using 2 force plates and were calculated by inverse dynamics. Results: There were significant differences between the groups in the walking velocity, step length, stride length, single support, double support. In kinematics, the mean pelvic tilt (p

Purpose: The purposes of this study were to investigate the expression pattern of pro-inflammatory cytokines during distraction osteogenesis and to compare these with expression during simple fracture healing. Materials and Methods: Regenerated bones from the rat tibia subjected distraction osteogenesis and simple fracture healing models were harvested over three-week periods. Temporal expressions of mRNA of pro-inflammatory cytokines were investigated by RNase protection assay. Immunohistochemical studies for IL-6 were performed in postoperative day 7 and 9 tissue section specimens. Results: IL-1and IL-6 produced detectable signals, while IL-1, TNF and TNFdid not. The mRNA expressions of IL-1 and IL-6 were markedly upregulated on postoperative day 1 and then subsided to the preoperative level. IL-1 mRNA expression remained the same even when distraction began. However, IL-6 mRNA expression was reactivated during the distraction phase. Immunohistochemical study revealed the expressions of IL-6 not only at the transitional zone of the transchondroid ossification, in young osteoblasts lining newly formed trabeculae and in hematopoietic cells in the marrow but also in primitive mesenchymal cells at the distraction gap. Conclusion: Distraction strain re-induced IL-6 expression during distraction osteogenesis, which suggests that well-controlled inflammatory reaction might contribute to active new bone formation in distraction osteogenesis.

Purpose: To understand the relationship between the gait patterns in transverse plane and the torsional deformities (TD). Materials and Methods: We evaluated the clinical, radiological, and three-dimensional gait analysis data of 55 spastic hemiplegics with TD. We define the TD as follows: 1) femoral anteversion , 2) thigh foot angle , 3) severe foot deformities that could affect the foot progression angle (FPA). Results: There were 35 males and 20 females with an average age of 8.4 years. 49 patients (89.1%) showed pelvic compensation (PC). In the PC group, 27 patients (55.1%) showed physiologic FPA. However, 22 patients (44.9%) still showed in-toeing (19 patients) or out-toeing (3 patients) gait. Out of the 6 patients (10.9%) who did not showed PC, we could observe in-toeing, out-toeing gait, and physiologic FPA from 3, 2, and 1 patients, respectively. 51 patients (92.7%) had increased femoral anteversion. There were 11 patients (19.6%) with an internal (2 patients) or an external tibial torsion (9 patients), and 30 patients (54.5%) with foot deformities. Conclusion: We classified the gait patterns and analyzed the relationship between each gait pattern and types of torsional deformities.

Purpose: The purpose of this study was to determine the incidence, location and contributing factors of the bony spur formation following lateral condyle fracture of the humerus in children. Materials and Methods: Sixty four lateral condyle fractures of the humerus followed up until bony union were retrospectively reviewed in the type of fracture, accuracy of the reduction, and the formation, size, location of the bony spur on serial radiographs. Treatment method was recorded. Results: In all children but one case showed bony spur formation in plain radiograph, be it large or small. The size of bony spur was not correlated with the extent of displacement nor treatment methods, but significantly related with the accuracy of reduction. In long term follow-up, the bony spurs decreased in size. Conclusion: Accuracy of reduction determinates the size of bony spur following lateral condyle fracture of the humerus in children. In order to prevent or minimize the bony spur formation, accurate reduction is desirable. Even if bony spur formation was present in early healing stage, it can be expected to decrease in size.

Purpose : The purpose of this study was to investigate the distribution of diseases and the orthopedic procedures performed in patients with genetic and metabolic bone diseases. Materials and Methods : One hundred and fifty-three patients, who were admitted to the orthopedic ward under a diagnosis of genetic or metabolic bone disease from January 1990 to December 2000, were investigated. Their medical records, radiographs and laboratory data were reviewed, and orthopedic procedures analyzed. Results : One hundred and fifty-one cases were diagnosed with specific diseases, while 2 remained unspecified. Achondroplasia, multiple epiphyseal dysplasia-pseudoachondroplasia and metaphyseal chondrodysplasia were common among the skeletal dysplasia cases. Hypophosphatemic rickets and osteogenesis imperfecta were common diseases among the metabolic and connective tissue categories. Limb lengthening was frequently performed in achondroplasia and in hypophosphatemic rickets, while deformity correction and hip surgery were frequent in multiple epiphyseal dysplasia - pseudoachondroplasia and metaphyseal chondrodysplasia. Conclusion : In genetic and metabolic bone diseases, only a limited number of clinical problems can be solved by orthopedic procedures. As new techniques are developed the pattern of orthopedic treatmen may change.

Purpose: We report the results of cyclic intravenous pamidronate therapy for children with osteogenesis imperfecta. Materials and Methods: Fourteen patients with mean age 2.7 years were included in this study. Clinical evaluation included: fracture frequency, height gain, activity of daily living, and subjective changes. Bone mineral densitometry, simple radiographic findings, and the change in vertebral height were evaluated. Serum levels of calcium, osteocalcin and the urinary excretion of calcium and N-telopeptide of type I collagen (NTx) were monitored. Histologic study was performed on iliac crest apophysis biopsy samples. Results: Fracture frequency significantly decreased, from a pre-treatment 0.99 per year per patient to 0.28 per year per patient duringtreatment. Height gain was not affected. Five patients reported subjective improvement. Bone mineral density increased in both lumbar spine and the femur neck. Urinary excretion of NTx and calcium were significantly reduced during each treatment cycle, but were restored at the following cycle. Eleven patients had transient asymptomatic hypocalcemia. A transient febrile reaction was observed in 8 patients during the first cycle, and 4 patients showed a mild increase in the serum transaminase level. Conclusion: Cyclic intravenous pamidronate treatment is safe and effective for children with osteogenesis imperfecta.

Purpose : The purpose of this study was to evaluate the post-operative changes and to determine the factors affecting results obtained after surgical correction of spastic equinus deformity. Materials and Methods : Among cerebral palsy patients who had received Tendo Achilles Lengthening (TAL) or the Strayer procedure, eighty nine patients (114 cases: TAL, 78 cases and Strayer, 36 cases) were included in this study. We evaluated clinical assessment data, kinematic data, and kinetic data pre- and post-operatively, according to the geographic type of cerebral palsy, age at operation, and sex. Results : Clinically, equinus deformities were corrected with an increased passive range of motion of the ankle in both groups. According to the kinematic results, both groups showed a normal ankle motion pattern with an increased dynamic range of motion. Kinetic results revealed that peak plantarflexor moment and power generation (A2) increased in both groups and that this increase was statistical significant in TAL group. Conclusion : Both the TAL and Strayer procedures corrected the spasticity and equinus deformity, and resulted in an increased dynamic range of motion of the ankle joint without compromising the triceps power. However, care must be taken not to decrease power generation when TAL is performed in diplegic cases older than 13 years of age.

Purpose : The purpose of this study was to investigate the effects of growth hormone (GH) on muscle during limb lengthening. Materials and Methods : Sixty rats underwent tibial lengthening of approximately 30% using a protocol consisting of a latency period of 4 days, a distraction period of 30 days with a rate of 0.25 mm twice per day, and a consolidation period of 27 days. Recombinant GH was administered to 30 of the rats (100/kg/day) and the same dose of normal saline to the remaining 30 rats, during the period from operation to sacrifice. Histopathologic, immunohistochemical, and electrophysiologic studies were performed on the tibialis anterior to compare the muscle responses of GH treated lengthened limbs (GL), GH treated non-lengthened limbs (GN), saline treated lengthened limbs (CL), and saline treated non-lengthened limbs (CN) at postoperative days 34 and 61. Results : Histologic injury scores were worst in the CL, in which vimentin expression was also greatest. Cell proliferation, determined by proliferating cell nuclear antigen (PCNA) staining, was greatest in the GL, in which desmin expression was also greatest. Electrophysiological methods showed better muscle function was retained in the GL than the CL. Conclusion : These results suggest that GH can reduce muscle damage during limb lengthening by enhancing myogenesis and decreasing fibrogenesis.

Purpose : Forearm lengths in cases of unilateral congenital radioulnar synostosis, were analysed radiographically to evaluate the amount of length discrepancy according to different types. Materials and Methods : We measured the ulnar length ratio (length of affected forearm/length of unaffected forearm) in 15 cases of unilateral congenital radioulnar synostosis. We observed two distinct radiographic patterns. Type I (Lamda type) appeared to be of character grossly, and showed severe radial bowing and a severely hypoplastic radial head. Type II (Chi type) seemed like in character, showed mild radial bowing and a mildly hypoplastic, or normal radial head. Results : Nine cases were type I and 6 were type II. The ulnar length ratio was 0.89 in type I and 0.98 in type II. Significant differences were formed in the ulnar length ratios between normal subject and type I, and between type I and type II (page (year)'. Conclusion : Unilateral congenital radioulnar synostosis can be classified into two types according to radiological morphology. This classification can be helpful in the prediction of forearm length discrepancy, and in the determination of surgical treatment type.

Purpose : The objectives of this study were to clarify the efficacy of the calcaneal lengthening procedure for flatfoot deformity in spastic conditions, and to identify factors affecting results after calcaneal lengthening. Materials and Methods : Ninety-eight feet in sixty patients were included in this study. The average age was 9.5 years and mean followup was 2.4 years. The following comparisons were made pre- and post-operatively: clinical, radiographic, kinematic, kinetic changes, and type of bone graft. Results : Seventy five feet (77%) showed excellent or good clinical results. Decreased longitudinal arch was the most resistant component after calcaneal lengthening. All of the radiological indices improved significantly, and were within the normal range, except calcaneal pitch post-operatively. Pre-operative calcaneal pitch was the most sensitive index for predicting the end result. According to 3-D gait analysis, peak knee flexion during early swing increased from to on average, and exaggerated dorsiflexion of the ankle in the stance phase improved to the normal range with restoration of first rocker action post-operatively. Foot progression angle, which averaged of external progression pre-operatively, improved to of external progression post-operatively. Peak and A2 power generation of the ankle increased post-operatively. Conclusion : Calcaneal lengthening proved an effective procedure for improving foot function, foot progression angle and knee flexion, and for increasing ankle power generation by increasing the foot lever arm.