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Background Varus knee correction may affect the ankle and subtalar joints and impact the prognosis of ankle arthritis because the weight-bearing load on the lower extremity extends from the hip to the foot. We aimed to evaluate the changes in the mechanical axis and the weight-bearing axis of the ankle after varus knee surgery. Methods Patients with a varus knee were followed up after undergoing high tibial osteotomy or total knee replacement arthroplasty. The inclusion criteria were age (>18 years) and a history of preoperative and postoperative scanograms. The postoperative change to the ankle joint axis point on the mechanical axis and weight-bearing axis according to the hip–knee–ankle angle correction was adjusted by multiple factors using a linear mixed model. Results Overall, 257 limbs from 198 patients were evaluated. The linear mixed model showed that the change in the ankle joint axis point on the mechanical axis was not statistically significant after high tibial osteotomy and total knee replacement arthroplasty (p = 0.223). The ankle joint axis point on the weight-bearing axis moved laterally by 0.9% per degree of postoperative hip–knee–ankle angle decrease (p Conclusions Varus knee correction could affect the subtalar joint and the ankle joint. Our findings require consideration when utilized during pre- and postoperative evaluations using the weight-bearing axis of patients undergoing varus knee correction.

Background Some patients with cerebral palsy (CP) exhibit excessive knee flexion at initial contact followed by knee hyperextension (KE) in mid-stance. Research question This study investigated the change in sagittal kinematics after distal hamstring lengthening (DHL) and triceps surae lengthening procedures in CP patients with KE, and compared it to those without KE. In addition, the risk factors for the worsening of postoperative KE were analyzed. Methods Consecutive 312 patients (596 limbs) with CP who underwent DHL and triceps surae lengthening were included. All patients underwent preoperative and 1-year postoperative three-dimensional gait analysis. Patients’ limbs were divided into the KE and knee flexion (KF) groups, according to preoperative minimum knee flexion in stance. KE was defined as minimum knee flexion in stance less than 0°. Results The KE and KF groups included 130 and 466 limbs, respectively. Knee and ankle sagittal kinematics significantly improved after surgery in both groups. Minimum knee flexion in stance significantly increased from -6.6˚ to 0.5˚ in the KE group, but decreased from 14.6˚ to 7.8˚ in the KF group. Among the KE group, minimum knee flexion in stance improved in 103 limbs (79.2 %), but worsened in 27 limbs (20.8 %). Degree of preoperative KE was the only factor significantly associated with postoperative worsening of KE (p=0.002). The cutoff value for the worsening of KE was -5.8˚ of preoperative minimum knee flexion in stance. Significance This study demonstrated that the sagittal kinematics of the knee and ankle joints improved after DHL and triceps surae lengthening procedures in CP patients with and without KE. Preoperative degree of KE was a risk factor for the worsening of KE after surgery. Therefore, careful selection for indication of DHL is required to prevent postoperative KE due to overlengthening of the hamstrings, particularly in patients with severe preoperative KE.

Background This study evaluate the radiographic changes in the mid-tarsal joint, including the calcaneocuboid and talonavicular (TN) joints after calcaneal lengthening for planovalgus deformity in children. Methods This study included 38 patients (68 feet) who underwent calcaneal lengthening for planovalgus deformity. Radiographic osteoarthritic changes at the CC or TN joint were defined as modified Kellgren–Lawrence grade of ≥1. Results Among the 68 feet, 31 feet (45.6%) showed radiographic osteoarthritic changes at the CC joint and 20 (29.4%) showed changes at the TN joint. Risk of radiographic osteoarthritic changes at the CC joint was associated with increased age at surgery (OR = 1.2, p = 0.038). Risk of radiographic osteoarthritic changes at the TN joint was associated with increased age at surgery (OR = 2.2; p = 0.002), preoperative AP talus-1st metatarsal angle (OR = 1.1; p = 0.044), and degree of CC subluxation (OR = 2.1; p = 0.007). Conclusions Surgeons should consider the risk factors in the surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.

This study aimed to estimate the annual change in radiographic indices for juvenile hallux valgus (JHV) and to analyze the factors that influence deformity progression.Patients aged15 years who had JHV and were followed up for at least 1 year were included. Hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-first metatarsal angle, and lateral talo-first metatarsal angle were evaluated. The progression rate of HVA was adjusted by multiple factors by using a linear mixed model.A total of 133 feet were included. The HVA and distal metatarsal articular angle both increased by 0.8° per year (p0.001 and p=0.003, respectively). HVA increased by 1.5° per year (p0.001) at under the age of 10, and the HVA progression in the older patients was not statistically significant.JHV deformity could progress with aging. Most deformity progression could occur before the age of 10 years.

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

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.This study included 590 subjects (0-15 years), who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis were recorded. Tibiofibular overlap, tibiofibular clear space, medial clear space, talar tilt, talocrural angle, relative fibular width and fibular position were measured.All radiographic measurements showed good to excellent intraobserver and interobserver reliability (ICCs, 0.603 to 0.949). The timing of ossification of medial malleolus and appearance of tibial incisura between boys and girls were not different. Tibiofibular clear space on mortise views, 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 AP view of both sides was50% in 97.1%, 93.1%, and 97.2% of patients, respectively. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on mortise view of both sides was50% in 98.0%, 96.5%, and 100% of patients, respectively.For skeletally immature patients, the criteria for absolute radiographic values used in adults to assess distal tibiofibular syndesmosis or deltoid ligament injury cannot be applied, but comparison of both sides of ankle joint could help physicians to predict the need for additional evaluations.

Femoral derotation osteotomy (FDO) is generally reported to be excellent for correcting the hip rotation and foot progression angles in children with cerebral palsy (CP). However, it is unclear how long the favorable outcomes are maintained.This study was performed to evaluate the long-term outcomes at more than 10 years after FDO in children with CP.FDO, as part of single event multilevel surgery to improve gait function, was performed at the intertrochanteric level with the patient in the prone position. The goal of the index surgery was femoral anteversion of 15°, measured using a modified trochanteric prominence angle test intraoperatively. All patients underwent three-dimensional gait analysis preoperatively and at 1 year and over 10 years postoperatively.Thirty-four ambulatory patients (53 hips) with CP undergoing FDO were included. The mean age at surgery was 7.8 years (SD = 3.0 years) and mean follow-up duration was 12.9 years (SD = 2.7 years). The mean hip rotation decreased significantly from 9.6° preoperatively to 3.1° at 1 year postoperatively (p = 0.004), and decreased significantly to -5.9° at the final follow-up (p 0.001). The mean foot progression in stance decreased from 7.9° preoperatively to -7.4° at 1 year postoperatively (p 0.001), and was maintained at -10.9° at the final follow-up. The GDI significantly improved from 68.2 preoperatively to 83.4 1 year postoperatively (p 0.001), and was maintained at 82.3 at the final follow-up. No patients underwent revision surgery due to recurrence of rotation deformity.Proximal FDO performed in the prone position provides favorable long-term outcomes at more than 10 years postoperatively, without recurrence of rotation deformity. To avoid under-correction or recurrence due to insufficient derotation, surgeons should consider not only dynamic gait analysis findings but also the measurement of anatomic femoral anteversion during intraoperative derotation.

Abnormal foot kinematics is observed in flatfoot subjects with postural foot deformity. We aimed to investigate joint instability in flatfoot subjects by analyzing the abnormal rotational position and speed of their joints while walking. Five flatfoot subjects participated in our study. Three-dimensional motions of the tibia, talus, calcaneus, navicular, and cuboid were obtained during walking using the biplanar fluoroscopic motion analyses. An anatomical coordinate system was established for each bone. The rotations and ranges of motion (ROMs) of the joints from heel-strike to toe-off were quantified. The relative movements on the articular surfaces were quantified by surface relative velocity vector analysis. The data from flat foot subjects were compared with the data from normal foot subjects in previous studies. The average relative speed on the articular surface of the tibiotalar, subtalar, and calcaneocuboid joints for the flatfoot subjects was significantly higher (p 0.05) than that for the normal foot subjects. The flatfoot subjects exhibited increased movements toward plantar flexion in the tibiotalar joint, and eversion and external rotations in the talonavicular joint during the stance phase, compared to the normal subjects (p 0.01). Furthermore, the flatfoot subjects had a significantly larger ROM along with the inversion/eversion rotations (5.6 ± 1.8° vs. 10.7 ± 4.0°) and internal/external rotations (7.1 ± 1.5° vs. 10.5 ± 3.5°) in the tibiotalar joint. The flatfoot subjects demonstrated abnormal kinematics and larger joint movements in multiple joints during the mid-stance and terminal stance phases of walking. This demonstrates their high instability levels.

Introduction The objectives of this study were to evaluate the correlation between bone attenuation around the shoulder joint assessed on conventional computed tomography (CT) and bone mineral density (BMD) based on dual-energy X-ray absorptiometry (DEXA) of the central skeleton and the correlation between the bone quality around the shoulder joint and the severity of the fracture pattern of the proximal humerus. Materials and methods A total of 200 patients with proximal humeral fracture who underwent preoperative 3-dimensional shoulder CT as well as DEXA within 3 months of the CT examination were included. Fracture types were divided into simple and comminuted fracture based on the Neer classification. After reliability testing, bone attenuation of the glenoid, three portions of the humeral head, and metaphysis was measured by placing a circular region of interest on the center of each bony region on CT images. Partial correlation analysis was used to assess the correlation between the bone quality around the shoulder joint on CT and the BMD on the central skeleton after adjusting for age and body mass index. Partial correlations between fracture classification and CT/DEXA results were also evaluated. Results Bone attenuation measurements of the glenoid and humeral head showed good to excellent reliability (intraclass correlation coefficient, 0.623–0.998). Bone attenuation of the central portion of the humeral head on CT showed a significant correlation with the BMD of L1, L4, the femoral neck, and femoral trochanter (correlation coefficient, 0.269–0.431). Bone attenuation of other areas showed a lower correlation with BMD by DEXA. As the level of the Neer classification increased from a 2 to 4-part fracture, bone attenuation of the central humeral head decreased significantly (r = −0.150, p = 0.034). However, the BMD on DEXA was not a predictive factor for comminuted fracture of the proximal humerus. Conclusions DEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus and severity of proximal humeral fracture. Direct assessment of the bone quality of the proximal humerus is recommended to determine the osteoporotic nature of the fracture.

To investigate the association between high-sensitivity C-reactive protein (hs-CRP) and lower urinary tract symptoms in healthy middle-aged men.A total of 4256 ostensibly healthy native Korean men between the ages of 40 and 65 years who voluntarily underwent medical checkup were enrolled. The participants' demographics were collected, including International Prostate Symptom Score, hs-CRP, various metabolic risk factors, and prostate volume (PV). Multivariate regression analyses were performed to investigate the relationship between hs-CRP and lower urinary tract symptoms after adjustment for age, PV, metabolic syndrome, and body mass index (BMI).Data obtained from 3539 men were analyzed. The mean age was 51.75 ± 7.01 years, and the mean C-reactive protein (CRP) level was 0.137 ± 0.256 mg/L. Correlation analysis after adjustment for age, PV, and BMI revealed that CRP only correlated with storage symptoms (coefficient = 0.044, P value = .007) and not voiding symptoms. Multivariate analysis using the full model revealed that age and CRP were positively correlated with storage symptoms (P.001 and .008, respectively). Multivariate analysis using a stepwise model revealed that age, CRP, and triglycerides were positively correlated with storage symptoms (P.001, .007, and .022, respectively) and BMI was negatively correlated with storage symptoms (P = .023).In healthy men, hs-CRP was independently correlated with storage symptoms after adjustment for age, BMI, PV, and metabolic risk factors. Subclinical inflammation might play a role in the pathophysiology of storage symptoms.

Objectives To characterize voiding symptoms during the peri- and post-menopausal periods and to investigate related hormonal changes. Methods We enrolled a total of 55 patients between February 10, 2013, and August 15, 2013, to participate in this cross-sectional study. To characterize patients’ voiding symptoms, we administered voiding questionnaires, including the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), and Sandvik Severity Index. Measured hormones included E2, FSH, TSH, prolactin, progesterone, and testosterone. Results In the univariate analysis, there were significant intergroup differences for all of the hormones except progesterone. Among the voiding symptoms, straining (IPSS question 1), frequency (IPSS question 2), and SUI were significantly different between the two groups ( p = 0.039. 0.010, and 0.017, respectively). In the multivariate analysis, frequency (IPSS question 2) and SUI were significantly different between the two groups ( p = 0.020 and 0.011, respectively). Among the hormones, only testosterone was marginally different between the two groups ( p = 0.059). Conclusions During the transition to menopause, voiding symptoms, such as frequency, can potentially worsen in the peri-menopausal period, and SUI is more prevalent in the post-menopausal period. Additionally, testosterone may have a role in voiding changes that occur during the menopausal transition.

Although several studies have reported on the outcomes of rectus femoris transfer (RFT), few have investigated the multiple factors that could affect the results. Therefore, we evaluated the outcomes of RFT and analyzed factors that influence improvement and annual change in knee motion after surgery in patients with cerebral palsy (CP).We reviewed ambulatory patients with CP who were followed up after they had undergone RFT as part of a single-event multilevel surgery (SEMLS) and who had undergone preoperative and postoperative three-dimensional (3D) gait analysis between January 1995 and December 2012. Relevant kinematic values, including peak knee flexion, knee range of motion, and timing of peak knee flexion in the swing phase and gait deviation index (GDI) score, were the outcome measures. Improvements in rate of angle and GDI score were adjusted by multiple factors such as sex, Gross Motor Function Classification System (GMFCS) level, anatomic type of CP, and concomitant surgeries as the fixed effects, and follow-up duration, laterality, and each subject as the random effects, all of which was performed using a linear mixed model.A total of 290 patients (487 limbs) and 612 3D gait analysis (2-4 per patient) results were finally included in this study. At 2 years after RFT, estimated mean peak knee flexion (1.2°, p=0.005), estimated mean knee range of motion (10.7°, p0.001), and estimated mean GDI score (7.3, p0.001) increased significantly. Peak knee flexion in the swing phase occurred 5.4% earlier after surgery compared with that at baseline (p0.001). In serial postoperative gait analyses, peak knee flexion in the swing phase occurred 0.8% earlier per year in patients with GMFCS level I or II (p=0.021).RFT as part of a SEMLS was effective in treating stiff knee gait. In serial postoperative gait analyses, patients with GMFCS level I or II showed better prognosis than those with level III with regard to timing of peak knee flexion in the swing phase.Prognostic level IV.