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Tibial torsion lacks a single and reliable method for its measurement. While physical examination, computed tomography (CT), and EOS imaging are used complementarily, three-dimensional (3D) CT is the most widely used method for intuitive documentation and visualization. However, concern regarding the associated radiation hazard limits its use in the evaluation of pediatric patients. Moreover, EOS machines are too expensive and too large to be placed in every clinic requiring the measurement of tibial torsion. Therefore, a new method for 3D reconstruction is needed. In the present study, we tested the validity and reliability of a novel reconstruction tool for the lower leg.A statistical shape model and Laplacian constraint were adopted for the development of a new reconstruction tool for measuring tibial torsion. Tibial torsion measurements based on a 3D reconstruction application and CT images for 36 patients were evaluated for intraobserver and interobserver reliability. Tibial torsion measurements for 75 patients were compared for validation.A 3D reconstruction system for the lower leg was developed as a mobile application and was installed in a portable device for easy access in the clinical setting. In terms of interobserver reliability, the intraclass correlation coefficient among 3 clinicians was 0.896 (95% confidence interval [CI], 0.828 to 0.941). The correlation coefficient between tibial torsion measured with use of 3D CT and that measured with the mobile application was 0.865 (p0.001).The mobile application showed excellent reliability and validity for measuring tibial torsion. Concurrent utilization with mobile application for the femur allows visualization of the rotational profile of the leg without the need for CT or EOS.Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Children with cerebral palsy (CP) often have changes in proximal femoral geometry. Neck-shaft angle (NSA), Hilgenreiner epiphyseal angle (HEA) and head-shaft angle (HSA) are used to measure these changes. The impact of femoral rotation on HEA/HSA and of ab/adduction on HEA/HSA/NSA is not well known. This study aimed to determine and compare the effect of rotation, ab/adduction and flexion/extension on HEA/HSA/NSA. Radiographic measurements from 384 patients with Gross Motor Function Classification System (GMFCS) levels I-V were utilized. NSA/HSA for affected hips were used with femoral anteversion averages to create three-dimensional models of 694 hips in children with CP. Each hip was rotated, ab/adducted and flexed/extended to simulate malpositioning. HEA/HSA/NSA of each model were measured in each joint position, and differences from correct positioning were determined. Mean HEA error at 20° of internal/external rotations were -0.60°/3.17°, respectively, with the NSA error of -6.56°/9.94° and the HSA error of -3.69°/1.21°. Each degree of ab/adduction added 1° of the HEA error, with no NSA/HSA error. NSA was most sensitive to flexion. Error for all measures increased with increasing GMFCS level. HEA/HSA were minimally impacted by rotation. NSA error was much higher than HEA/HSA in internal rotation and flexion whereas HEA was sensitive to changes in ab/adduction. Given abduction is more easily detectable on imaging than rotation, HEA may be less affected by positioning errors that are common with children with CP than NSA. HSA was least affected by position changes. HEA/HSA could be robust, complementary measures of hip deformities in children with CP.

OBJECTIVE We aimed to investigate the progression of patella alta (PA) in patients with cerebral palsy (CP) using the Koshino-Sugimoto (KS) index and assess associated risk factors. METHOD Participants in our retrospective study met the following inclusion criteria: patients with CP who visited our institute from May 2003 to December 2019, were ≤18 years of age, were followed up for >2 years and had at least two lateral knee radiographs. KS indices of both knee radiographs were measured for each patient. A linear mixed model was implemented. RESULTS Our participants included 222 CP patients. KS index values were measured via 652 knee radiographs. Reference values of the KS index for those between 4 and 18 years of age were determined according to Gross Motor Function Classification System (GMFCS) levels. In all GMFCS levels, the KS index decreased with patients' ages (P < 0.0001). In groups where the KS index increased, GMFCS levels IV (P = 0.0045) and V (P = 0.0040) were statistically significant. CONCLUSIONS Change in the KS index values indicates that PA improves as patients age within all GMFCS levels. However, in patients with GMFCS levels of IV and V, progressive PA is expected.

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.

Intraosseous alignment of the tarsal bone has not been investigated in relation to various foot deformities. This study aimed to investigate three-dimensional computed tomography (3D CT) talar morphology in children with idiopathic and neuromuscular pes planovalgus. Eleven children [nine boys, two girls; mean (SD) age: 10.5 (2.8) years] with idiopathic pes planovalgus and 15 children [three boys, 12 girls; mean (SD) age: 10.8 (3.4) years] with neuromuscular pes planovalgus were included. All patients underwent 3D CT and weight-bearing anteroposterior, lateral, and axial radiography. Demographic data and talar 3D CT and radiographic measurements were compared between both groups. The correlation between the measurements was also analyzed. The neuromuscular group showed significantly more severe deformity than the idiopathic group in the radiographic and 3D sagittal talus measurements. The 3D coronal talus measurement showed a significant negative correlation with the axial hindfoot alignment in the idiopathic group while the 3D transverse talus measurement was significantly correlated with the lateral talocalcaneal angle in the neuromuscular group. 3D intraosseous alignment of the talus is correlated with pes planus deformity. Longitudinal and biomechanical studies including a control group are necessary to elucidate the role of 3D talar morphology on a dynamic imbalance in pes planovalgus.

Calcaneal lengthening (CL) is one of the treatment options for planovalgus deformity in patients with cerebral palsy (CP). However, its indication still needs to be clarified according to the functional status of CP. The aim of this study was to investigate the radiographic outcome after CL in patients with CP and to evaluate the risk factors causing undercorrection of planovalgus deformities. We included consecutive patients with CP who underwent CL for planovalgus deformity, were followed for more than 2 years, and had preoperative and postoperative weight-bearing anteroposterior (AP) and lateral foot radiographs. Six radiographic indices were used to assess the radiographic outcome. The patient age, sex, and Gross Motor Function Classification System (GMFCS) level were evaluated as possible risk factors, and we controlled for the interaction of potentially confounding variables using multivariate analysis. A total of 44 (77 feet) patients were included in this study. The mean age of the patients at the time of surgery was 10.5±4.0 years and the mean follow-up was 5.1±2.2 years. Patients with GMFCS III/IV achieved less correction than those with GMFCS I/II in the AP talus-first metatarsal angle (P=0.001), lateral talocalcaneal angle (P=0.028), and the lateral talus-first metatarsal angle (P

Proximal femoral osteotomy has been used in cerebral palsy, Perthes disease, hip dysplasia, idiopathic femoral anteversion, and various hip diseases in children and adolescents. Conventionally, a blade plate (BP) has been used. However, the pediatric locking compression plate (LCP) has recently been applied widely. We compared the hardware-related complications of the BP and the LCP as well as the factors influencing these complications in patients who have undergone a proximal femoral osteotomy in children and adolescents. We enrolled consecutive patients aged less than or equal to 20 years who had undergone proximal femoral osteotomy with BP or LCP between May 2003 and December 2014, and who were followed up until 6 months after hardware removal. Following consensus building, hardware-related complications were identified from the patients' medical records and hip radiographs. Patient age, sex, type of plate, and Gross Motor Function Classification System (GMFCS) level in cerebral palsy patients were evaluated as possible risk factors, and a generalized estimating equation was used to assess the risk factors for hardware-related complications. A total of 417 hips from 251 patients were finally included in this study. Seven losses of fixation around the plate (five patients, 3.0%) occurred in the BP, three implant-related fractures (three patients, 3.6%) occurred in the LCP, and there was no significant difference (P=0.74). All hardware-related complications occurred in cerebral palsy patients, and the implant-related fractures occurred in patients with GMFCS IV/V. The risk of complications increased with age (P=0.002). The risk of loss of fixation around the BP is a well-known complication. However, LCP is not without hardware-related complications. The LCP provides strong stability of fixation. However, it is speculated that the LCP is related to implant-related fractures because of the stress shielding effect. Therefore, care should be exercised when using a locking plate in patients with osteoporosis, such as cerebral palsy with GMFCS IV/V. LEVEL OF EVIDENCE Therapeutic Level III.

There has been no study evaluating the change of limb alignment for patients with genu valgum. The purpose of this study was to investigate the change of limb alignments in children and adolescents with idiopathic genu valgum through evaluating distal femur, proximal tibia, and knee joint line. Consecutive children and adolescents, under the age of 18, with genu valgum were included. Mechanical tibiofemoral angle, mechanical lateral distal femoral angle, mechanical medial proximal tibia angle, and joint line convergence angle were measured. The rate of changes for each radiographic measurement were analyzed using a linear mixed model. A total of 1539 teleroentgenograms from 518 limbs of 273 individuals were included in this study. Linear mixed model showed that the change of limb alignment was significantly associated with age, but not associated with gender and laterality. The mechanical tibiofemoral angle was most valgus initially, decreasing until reaching its lowest value of 2.8° at 10 years old. The mechanical lateral distal femoral angle decreases from initial neutral alignment and increases in valgus continuously. The mechanical medial proximal tibia angle decreases from initial valgus and progresses to be neutral at around the age of 10. The joint line convergence angle decreases sharply from initial valgus alignment to 0° at the age of 5. Valgus alignment in children with idiopathic genu valgum decreases until approximately the age of 10. In younger children, the tibia and joint line contribute most to overall valgus alignment; in older children, the femur contributes the most. Based on our results, we recommend monitoring patient limb alignment until it stabilizes around the age of 10, and then carefully planning and performing corrective surgery with complete consideration of the changing bony alignment.

BACKGROUND Fibular shortening is one of the most common causes of ankle valgus deformity in children, and is frequently observed in patients with hereditary multiple exostoses (HME). It has been observed that the lateral distal tibial angle (LDTA) measured on the teleoradiograph differs from that on the ankle anteroposterior (AP) radiograph. The effect of the beam projection angle in the measurement of ankle valgus deformity associated with fibular shortening in HME patients was investigated. METHODS Fourteen ankles showing valgus deformity associated with fibular shortening from 14 HME patients comprised the short fibula group. Nineteen ankles with normal ankle alignment from 19 patients comprised the control group. The LDTA on the AP radiograph, teleoradiograph, and 3 coronal planes of 3-dimensional computed tomographic scans were measured and compared. RESULTS In the short fibula group, the LDTA measured on the ankle AP radiograph was significantly larger than that on the teleoradiograph (79.6±4.3 vs. 75.0±6.2 degrees, P=0.001), whereas there was no significant difference in the control group (P=0.36). In the short fibula group, the LDTAs measured on the 3 coronal planes of 3-dimensional computed tomography showed that the ankle valgus measurement significantly increased from anterior to posterior planes (P=0.001), whereas there was no significant difference in the control group (P=0.85). CONCLUSIONS Measurement of ankle valgus deformity depends on the direction of beam projection and ankle valgus deformity is more severe in the posterior coronal plane of the ankle joint. This discrepancy should be taken into consideration in the planning of ankle valgus deformity management. LEVEL OF EVIDENCE Level IV-diagnostic.

Background: The purposes of this study were to evaluate acetabular remodeling after closed reduction of developmental dysplasia of the hip (DDH) and to delineate the role of osteotomy. Methods: Eighty-four hips with DDH treated with closed reduction and followed until the patient was 8 years of age or older were included in this study. The mean age at closed reduction was 14.0 months (range, 3 to 30 months) and that at the latest follow-up visit was 12.7 years (range, 8.0 to 24.7 years). Osteotomy was performed in 26 hips (31%) during the follow-up period, at an average age of 2.8 years (range, 2.0 to 5.8 years). The acetabular index (AI) and center-edge angle (CEA) were measured, and osteonecrosis was graded. The treatment outcome was evaluated as satisfactory (Severin grade I or II) or unsatisfactory (III or IV). We retrospectively analyzed the associations among radiographic parameters, performance of osteotomy, grade of osteonecrosis, and final outcome. Results: A satisfactory outcome was observed in 67 (80%) of the 84 hips. An osteotomy was not performed in 30 of 34 hips with an AI of 14° at the age of 3 years, and 28 (93%) of these 30 hips showed a satisfactory outcome. Of the 33 hips with an AI of ≥32° and a CEA of ≤14° at the age of 3 years, the 20 that had undergone an osteotomy showed a higher proportion of satisfactory outcomes than the 13 hips that had not (p = 0.01). Three of the 4 hips that showed an unsatisfactory outcome following an osteotomy had an AI of ≥34° at 1 year post-osteotomy. Grade-II, III, or IV osteonecrosis, according to the Bucholz-Ogden classification, developed in 10 of the 84 hips, and these 10 hips had a higher proportion of unsatisfactory outcomes than did those that developed no or grade-I osteonecrosis (p = 0.004). Conclusions: Hips with DDH showing poor acetabular remodeling after closed reduction may benefit from osteotomy. The AI and CEA at the age of 3 years can serve as one of the guidelines for osteotomy. Continued surveillance for acetabular remodeling is required even after osteotomy. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Calcaneal lengthening with allograft is frequently used for the treatment of patients with symptomatic planovalgus deformity; however, the behavior of allograft bone after calcaneal lengthening and the risk factors for graft failure are not well documented.

BACKGROUND Intramedullary telescopic rod fixation has been used for stabilization of the long bones in growing children who have osteogenesis imperfecta. Proximal migration of the rod is the most common complication of telescopic rodding in the femur. The purposes of this study were to evaluate incidence and temporal pattern of proximal migration of the femoral rod, and to investigate factors related to it. METHODS A total of 50 patients with osteogenesis imperfecta, who had femur stabilized by telescopic rod with T-piece, were the subjects of this study. In patients having both the femora stabilized, only 1 femur was randomly selected for analysis. Hence, in 50 femora, migration-free survivorship was analyzed using the Kaplan-Meier method, and association with possible risk factors was analyzed by Cox regression analysis using the proportional hazards model. Factors investigated in the analysis include age at the time of surgery, sex, purpose of the index surgery, residual or developing angular deformity of the femur, rod position at the distal physis, persistent cortical gap at fracture/osteotomy site, Sillence classification, and type of telescopic rod. RESULTS Proximal migration was observed in 7 of 50 femora. Cumulative survival without proximal migration was 0.94 (95% CI, 0.87-1.01) in 1 year, and 0.85 (95% CI, 0.75-0.95) in 6 years. Factors significantly associated with proximal rod migration in Kaplan-Meier survivorship analysis and univariate Cox regression analysis were angular deformity, eccentric rod position at the distal physis, and persistent cortical gap. When these factors were analyzed by multivariate analysis, eccentric rod position at the distal physis was the only significant factor with a hazard ratio of 11.74. CONCLUSIONS The risk of proximal rod migration can be reduced by complete correction of angular deformity and optimal placement of the rod at the distal physis. Our data also suggest that developing angular deformity or persistent osteotomy/fracture gap requires special attention at the possibility of proximal rod migration during follow-up. LEVEL OF EVIDENCE Level III, prognostic study.

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.

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.

Slipped capital femoral epiphysis (SCFE) is rare in nonambulatory patients, as mechanical factors play important roles in the development of the disease. We report a case of SCFE, which occurred in a 12-year-old girl with a nonambulatory status after cerebral infarction. SCFE occurred after she received passive range of motion exercise and extracorporeal shock wave treatment for neurogenic heterotopic ossification around the hip joint. The patient was successfully managed by a stepwise approach, with radiological and clinical improvements.

The aim of this retrospective study was to determine the short-term effects of proximal femoral derotation osteotomy (FDO) on gait in 53 ambulatory patients with spastic diplegia controlling all confounding procedures. All patients showed a jump gait pattern and had undergone bilateral rectus femoris transfer, distal hamstring lengthening, and tendo-Achilles lengthening as a single-event multilevel surgery. Of these, additional bilateral proximal FDOs were included in 25 patients, defined as the FDO group; the other 28 patients were defined as the no-FDO group. Kinematic variables, such as pelvic tilt, minimal hip flexion in stance, hip rotation, and foot progression angle, were compared between the two groups at postoperative 1 year. Hip extension, hip rotation, and hip adduction improved significantly after surgery in the FDO group (P

We report a case of atlantoaxial rotatory subluxation developed after scapular relocation for Sprengel deformity in a 5-year-old girl. Scapular relocation descended the scapula by 60%, and achieved a normal shoulder joint motion. However, atlantoaxial rotatory subluxation developed, probably by pulling force of the tightened anterior fibers of upper trapezius muscle. Atlantoaxial joint was reduced easily under general anesthesia and muscle relaxant, along with surgical release of the tight band at the anterior part of trapezius muscle, which was maintained by halovest immobilization.

The choice of pinning techniques in supracondylar fractures of the humerus in children has been a debate regarding its fixation stability and risk of iatrogenic ulnar nerve palsy. This study was performed to determine as to which fixating method (medial and lateral crossed pinning vs. lateral pinning) is better for the displaced supracondylar fractures using a decision analysis tool in terms of function.A decision analysis model was designed containing the probability of iatrogenic ulnar nerve palsy and malunion caused by unstable fixation for each of lateral pinning and medial and lateral crossed pinning techniques. The final outcome was function adjusted life year and used as a utility in the decision tree, where function was evaluated using the McBride disability evaluation. The probabilities of all cases were obtained by literature review and assumptions. A roll back tool was used to determine the better pinning technique, and sensitivity analysis was performed to compensate for the uncertainty of the model.Overall, our decision model favored the lateral pinning technique over the medial and lateral crossed pinning with the utilities of 99.6 and 99.3 in terms of function adjusted life year. One-way sensitivity analysis showed that the threshold rate of iatrogenic ulnar nerve injury as a complication after medial and lateral crossed pinning was 0.7%, below which the model favored medial and lateral crossed pinning over lateral pinning. The decision model was found to be sensitive to the percentage of permanent ulnar nerve palsy after medial and lateral crossed pinning. Two-way sensitivity analysis showed that the lateral pinning technique was more beneficial than the medial and lateral crossed pinning technique.In our decision analysis model, the lateral pinning technique was found to be more beneficial than the medial and lateral crossed pinning technique for supracondylar fractures of the humerus in children, on the basis of current evidences. However, the results were sensitive to the data of ulnar nerve injury. Avoiding the worst clinical scenario (permanent ulnar nerve palsy) might be more important and affordable than obtaining favorable clinical results (stable fixation) at the potential cost of disastrous complications.Level III.

BACKGROUND Translation and transcultural adaptation of the Pediatric Outcomes Data Collection Instrument (PODCI) into Korean language was performed, and the validity was tested. METHODS Korean version of PODCI was produced according to internationally accepted guideline, which included preparation, forward translation, reconciliation, back translation, review of back translation and harmonization, cognitive debriefing and review, and proof reading process. Eighty-two child controls (aged 5 to 10 y), 92 adolescent controls (aged 10 to 18 y), and 30 children with cerebral palsy (aged 5 to 10 y) undergoing single event multilevel surgery were included, and their parents also participated. Each subscale of Korean PODCI was tested in terms of internal consistency (Cronbach α), discriminant validity (difference of parental responses between child control and children with cerebral palsy), convergent validity (correlation between self-response and parental response in adolescent control), and responsiveness (postoperative changes of parental responses in children with cerebral palsy). RESULTS All subscales except pain/comfort showed sufficient internal consistencies (Cronbach α > 0.7). Upper extremity/physical function, transfer/basic mobility, sports/physical functioning, and global functioning subscales showed significant discriminant validity (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively). Correlation between self-response and parental response in adolescent controls were significant in all subscales, being highest in transfer/basic mobility subscale (r = 0.952, P < 0.001) and lowest in happiness subscale (r = 0.548, P < 0.001). Responsiveness was significant in transfer/basic mobility (P < 0.001), sports/physical functioning (P=0.001), and global functioning (P = 0.006) subscales after single event multilevel surgery. CONCLUSIONS Korean version of PODCI showed relevant internal consistency, discriminant validity, convergent validity, and responsiveness except for pain/comfort and happiness subscales. Care need to be taken when evaluating subjective measures, such as pain/comfort and happiness subscales. LEVEL OF EVIDENCE Diagnostic level I.

BACKGROUND This study was performed to determine changes in Pediatric Outcomes Data Collection Instrument (PODCI) scores after single-event multilevel surgery (SEMS), and to evaluate the relationship between the improvements of PODCI scores and parental satisfaction after SEMS. METHODS Demographic data, preoperative and postoperative PODCI, functional assessment questionnaire (FAQ) walking scales, and self-reported parental satisfaction with SEMS were obtained from 61 parents of ambulatory patients with cerebral palsy [40 male, 21 female, mean age 10 y 2 mo (SD 3 y 8 mo), mean follow-up 2 y 2 mo]. Postoperative improvements in each subscale of PODCI and FAQ were analyzed, and multiple regression analysis was performed to identify the factors that contributed significantly to postoperative parental satisfaction. Rasch analysis was performed for the PODCI subscale that was clinically relevant. RESULTS FAQ, transfers/basic mobility, sports/physical activity, and global function subscales of PODCI significantly improved after SEMS. Age, gross motor function classification system level, and the amount of improvement in sports/physical activity subscale were found to affect parental satisfaction to SEMS significantly. However, the subscale showed insufficient item responses, and ceiling and floor effects. CONCLUSIONS Although changes in sports/physical activity subscale were relatively small, they were found to affect parental satisfaction with SEMS significantly. These indicate that clinicians and researchers should pay attention to sports and physical activities in patients with cerebral palsy. LEVEL OF EVIDENCE Diagnostic level I.

Patellar height is associated with various clinical syndromes. We asked which of three methods was the most appropriate for measuring patellar height for different age groups in terms of applicability, validity, and reliability. We evaluated 108 children and adolescents with available MR images and lateral knee radiographs using Insall-Salvati (IS), Blackburne-Peel, and Koshino-Sugimoto (KS) methods. Subjects were divided equally into three age groups (A, 5–10.9 years; B, 11–12.9 years; C, 13–18 years). The applicabilities of the three methods were evaluated using bony landmarks identified on lateral radiographs. For validation testing, standardized patellar tendon lengths determined by MRI were used as reference standards, and concurrent validity was analyzed by performing correlation tests. Intraobserver and interobserver reliability were determined using intraclass correlation coefficients. Of the three methods used to measure patellar height in this study, the IS appeared to be the most reliable and valid in patients older than 13 years with nearly complete ossification. Before this stage of ossification had been achieved, the KS was the only applicable and most reliable but less valid method in younger children. Level of Evidence: Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND This study was performed to identify issues of concern to parents after single-event multilevel surgery in ambulatory patients with cerebral palsy. METHODS Parents' reports of concern were obtained for 72 ambulatory patients with hemiplegic cerebral palsy (group H; mean age 8.7 y) and 170 ambulatory patients with diplegia (group D; mean age 8.9 y), who had undergone single-event multilevel surgery and were followed for more than 1 year (mean follow-up 5.5 y). Data were acquired using a postal survey. Issues of concern to parents were evaluated using a 5-point Likert scale (1 to 5) for each of 33 items, which was designed for this study. RESULTS The top 3 issues of concern after surgery were unequal limb circumference, the operative scar, and recurrence in group H, and the operative scar, play activity, and recurrence in group D. Overall concerns were greater in group D (P=0.001) whereas group H was more concerned about appearance such as unequal leg length and circumference (P=0.001

Background Few data are available concerning the indications, outcomes, or optimum timing of femoral osteochondroplasty in patients with late sequelae of septic arthritis of the hip. Methods This paper presents 2 unusual cases of Choi type II sequelae associated with a large osteocartilaginous prominence or bump of the femoral head, responsible for cam-type femoroacetabular impingement in preadolescence. Results Two active preadolescents presented with groin pain after activity, a slightly antalgic gait, and difficulty squatting fully. On physical examination, both had less than 20 degrees of internal rotation with the hip in 90 degrees of flexion and a positive impingement sign, whereby groin pain was provoked by hip flexion, adduction, and internal rotation. One patient underwent osteochondroplasty and femoral valgus osteotomy, and the other osteochondroplasty alone, through surgical dislocation. Postoperatively, both had markedly improved free hip motion and no impingement sign. Conclusions Patients with type II sequelae before reaching skeletal maturity may present with femoroacetabular impingement symptoms. These 2 cases show that impingement-free hip motion through surgical dislocation improves symptoms. Level of Evidence Retrospective study, level IV.

BACKGROUND The shape of the dysplastic acetabulum has been generally determined by 2-dimensional computed tomography (CT) measurements (transaxial CT indices), such as the anterior and posterior acetabular indices and acetabular anteversion. However, their reliability and validity in evaluating the acetabular coverage have not been confirmed. METHODS This study examined the reliability and validity of the transaxial CT indices using 2- and 3-dimensional CT analyses of the acetabulum before and after a Dega osteotomy. Twenty-two acetabuli from 16 patients with cerebral palsy with hip instability were examined. Interobserver and intraobserver reliability tests were performed, and the preoperative and postoperative measurements were compared for the concurrent and construct validity test. RESULTS The transaxial CT indices revealed substantial intraobserver and interobserver reliability. The concurrent validity of the anterior acetabular and posterior acetabular indices before osteotomy was moderate (r = 0.45, 0.49), whereas the construct validity after osteotomy was low when compared with 3-dimensional methods. CONCLUSION The transaxial CT indices are reliable and valid for assessing the acetabular coverage in the preoperative status. However, care should be taken when using these indices to assess the outcome of a pelvic-reshaping osteotomy because of their insufficient construct validity. LEVEL OF EVIDENCE Level III of diagnostic study.

A longitudinal study is among the most popular methods used to test hypotheses in orthopaedic research. However, clinical data analyses can present challenges in several situations. The following orthopaedic scenario will be used throughout this article; in this scenario, the data structure is longitudinal. A researcher evaluated the long-term outcomes of the Dega osteotomy1 in fifty patients (sixty hips) with symptomatic developmental dysplasia of the hip. The mean age at the time of the operation was thirty months, and the mean duration of follow-up was sixty months (range, twelve to 144 months). The clinical outcome was assessed with use of preoperative and postoperative radiographic evaluations of the acetabular index. The preoperative and postoperative radiographs were repeatedly assessed during the follow-up period. However, some patients may not have …

Background: Mycobacterial osteomyelitis involving only the epiphysis of a long bone is extremely rare, and its clinical and radiographic features remain unclear. The purpose of this study was to characterize mycobacterial epiphyseal osteomyelitis and to identify differences between its features and those reported for epiphyseal osteomyelitis caused by bacteria or unidentified pathogens. Methods: We retrospectively reviewed the cases of eight children (five males and three females) who presented at a median age of nineteen months (range, twelve to twenty-five months). Clinical findings were compiled. Radiographs and magnetic resonance imaging (MRI) were used to determine local spread of the abscess outside the epiphysis during the disease course. At the time of the latest follow-up evaluation, the presence of limited joint mobility or growth disturbance was determined. Physeal damage was evaluated with use of MRI. Results: Pathogens were identified through multiplex polymerase chain reaction. Mycobacterium bovis bacille Calmette-Guerin (BCG, Tokyo-172 strain) was identified in four patients; Mycobacterium tuberculosis, in three patients; and nontuberculous mycobacterium, in one patient. The lesion was located at the distal femoral epiphysis in six patients, at the proximal tibial epiphysis in one patient, and at the proximal humeral epiphysis in one patient. The abscess was confined to the epiphysis at the time of initial presentation but, over time, extended outside the epiphysis in seven cases. The lesion was initially located in the cartilaginous epiphysis in two patients, which could be diagnosed only on MRI. Seven patients worsened despite surgical drainage and medication, and five required additional surgery. At follow-up at a mean of 4.1 years (range, 1.3 to 7.8 years), focal physeal damage was evident in five patients, and clinical growth disturbance was evident in one patient. Conclusions: In contrast to the reported benign features of epiphyseal osteomyelitis caused by bacteria or unidentified pathogens, mycobacterial epiphyseal osteomyelitis seems to have an unfavorable clinical course that tends to lead to physeal damage. MRI is useful for early diagnosis of a cartilaginous lesion and evaluation of abscess spread and physeal damage. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.