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Background This study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images. Methods All patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated. Results A total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9–34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0–10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1–30.8%). The minimum ratio was 15.1%. Conclusion A percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury.

Background This study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures. Materials and methods This study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD Results Casting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p Conclusions Patients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys. Level of evidence Level III

Background The purpose of this study was to identify differences in caregiver responses to Korean-language and English-language versions of the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire. Methods Patient data were acquired from the Cerebral Palsy Hip Outcomes Project database, which was established to run a large international multicenter prospective cohort study of the outcomes of hip interventions in cerebral palsy. Thirty-three children whose caregivers had completed the Korean version of CPCHILD were matched by propensity scoring with 33 children whose parents completed the English version. Matching was performed on the basis of 12 covariates: age, gender, gross motor function classification system level, migration percentage of right and hip, seizure status, feeding method, tracheostomy status, pelvic obliquity, spinal deformity, parental report of hip pain and contracture interfering with care. Results There were no significant differences in CPCHILD scores for section 4 (Communication and Social Interaction), and section 5 (Health) between two groups. Korean-language CPCHILD scores were significantly lower than English-language CPCHILD scores for section 1 (Personal Care/Activities of Daily Living), section 2 (Positioning, Transferring and Mobility), section 3 (Comfort and Emotions) and section 6 (Overall Quality of Life) as well as in terms of total score. Conclusions Cultural influences, and the community or social environment may impact the caregivers’ perception of the health-related quality of life of their children. Therefore, physicians should consider these differences when interpreting the study outcomes across different countries.

Background Analyzing radiographic changes of pes planovalgus(PV) deformity of cerebral palsy(CP) patients according to age and influencing factors. Methods CP patients with PV deformity younger than 18 years old who had undergone more than a year of follow-up with at least two standing foot radiographs were included. Anteroposterior and lateral talo-first metatarsal(talo-1stMT), talo-second metatarsal(talo-2ndMT), and hallux valgus(HV) angles were measured on the radiographs. The rate of progression was adjusted by multiple factors using the linear mixed model, with the Gross Motor Function Classification System(GMFCS) level as the fixed effect and age and each subject as random effects. Results Overall, 194 patients were enrolled in this study, and 1272 standing foot radiographs were evaluated. The AP talo-2ndMT angle progressed by 0.59° (p p = 0.0007) in GMFCS level II and III patients, respectively; however, there was no significant change in GMFCS level I patients (p = 0.3269). HV was significantly affected by age in all three GMFCS groups; it increased by 0.48° (p p stMT angle (p = 0.0535). Conclusions The GMFCS level was the single most important factor influencing the progression of radiographic indices in PV deformity in CP. The AP talo-1stMT and talo-2ndMT angles progressed in patients with GMFCS levels II and III. Physicians should take this result into consideration when planning the timing of the surgery. Level of evidence Prognostic Level IV.

Background Dega pelvic osteotomy is commonly performed procedure in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for hip displacement. However, there has been no study investigating the outcomes after Dega pelvic osteotomy using allograft in patients with CP. This study investigated the outcomes of Dega pelvic osteotomy using iliac crest allograft in CP with hip displacement and the factors affecting allograft incorporation. Methods This study included 110 patients (150 hips; mean age 8y7mo; 68 males, 42 females) who underwent hip reconstructive surgeries including Dega pelvic osteotomy using iliac crest allograft. To evaluate the time of allograft incorporation, Goldberg score was evaluated according to the follow-up period on all postoperative hip radiographs. The acetabular index, migration percentage, and neck-shaft angle were also measured on the preoperative and postoperative follow-up radiographs. Results The mean estimated time for allograft incorporation (Goldberg score ≥ 6) was 1.1 years postoperatively. All hips showed radiographic union at the final follow-up and there was no case of graft-related complications. Patients with Gross Motor Function Classification System (GMFCS) level V had 6.9 times higher risk of radiographic delayed union than those with GMFCS level III and IV. Acetabular index did not increase during the follow-up period (p = 0.316). Conclusions Dega pelvic osteotomy using iliac crest allograft was effective in correcting acetabular dysplasia, without graft-related complications in patients with CP. Furthermore, the correction of acetabular dysplasia remained stable during the follow-up period.

Background Although several studies have investigated the outcomes after distal hamstring lengthening (DHL), no study has undertaken an approach that included all or most of the important factors that could influence the results. This study was performed to evaluate the outcomes after DHL and analyze the factors that influence the improvement and serial change in knee motion after surgery in patients with cerebral palsy (CP), using a linear mixed model (LMM). Methods The study included 314 ambulatory CP patients (594 limbs) with spsastic diplegia who were followed up after undergoing DHL as part of a single-event multilevel surgery and who underwent preoperative and postoperative 3-dimensional (3D) gait analyses. Relevant kinematic values, including knee flexion at initial contact, minimum knee flexion in the stance phase, knee range of motion (ROM), mean pelvic tilt and gait deviation index (GDI) score, were the outcome measures. Changes in knee motion and the GDI score were adjusted for multiple factors, such as sex, the Gross Motor Function Classification System (GMFCS) level, and concomitant surgeries as fixed effects, and follow-up duration, laterality, and each subject as random effects, using a LMM. Results We found significant improvements in knee flexion at initial contact, minimum knee flexion in the stance phase, knee ROM, and GDI score 2 years after DHL. In patients with GMFCS level I and II, improvement in all sagittal knee kinematics was maintained during follow-up. In addition, GDI score, which represents overall gait pathology, consistently improved throughout the follow-up duration (1.2 per year, p = 0.008). Conclusion Medial hamstring lengthening with semitendinosus transfer, as a part of a SEMLS, was effective procedure in treating flexed knee gait with regard to sagittal knee kinematics and GDI score in spastic CP with flexed knee gait.

The aim of this study was to investigate the gender- and body-site-specific factors associated with bone mineral density (BMD) at the femoral neck and lumbar spine in a non-institutionalized population aged ≥50 years characterized by low average calcium intake. The comprehensive data utilized were from the 2010 Fifth Korea National Health and Nutrition Examination Survey, which included health behavior questionnaire, blood and urine tests, dual-energy X-ray absorptiometry, and nutrition intake. The factors associated with BMD at the femoral neck and lumbar spine in both genders were analyzed separately using multiple regression analysis with a stepwise selection. The average daily calcium intake in the male subjects was 565.8 mg and in the female subjects was 443.7 mg. In multiple regression analysis, age, body mass index (BMI), alkaline phosphatase (ALP), lead, daily calcium intake, and cadmium were the significant factors associated with femoral neck BMD in male subjects. BMI, creatinine (Cr), total body fat percentile, lead, ALP, and hypertension were found to be the significant factors associated with lumbar spine BMD in male subjects. In the female subjects, the significant factors associated with femoral neck BMD were age, BMI, ALP, house income, and total body fat percentile, while menopause, Cr, mercury, house income, BMI, and ALP were found to be the significant factors associated with lumbar spine BMD. In conclusion, different factors were associated with BMD depending on gender and the body site tested (femoral neck or lumbar spine). These gender- and body-site-specific factors need to be considered for the prevention and management of osteoporosis.

Accurate quantification of bone morphology is important for monitoring the progress of bony deformation in patients with cerebral palsy. The purpose of the study was to develop an automatic bone morphology measurement method using one or two radiographs. The study focused on four morphologic measurements—neck-shaft angle, femoral anteversion, shaft bowing angle, and neck length. Fifty-four three-dimensional (3D) geometrical femur models were generated from the computed tomography (CT) of cerebral palsy patients. Principal component analysis was performed on the combined data of geometrical femur models and manual measurements of the four morphologic measurements to generate a statistical femur model. The 3D–2D registration of the statistical femur model for radiography computes four morphological measurements of the femur in the radiographs automatically. The prediction performance was tested here by means of leave-one-out cross-validation and was quantified by the intraclass correlation coefficient (ICC) and by measuring the absolute differences between automatic prediction from two radiographs and manual measurements using original CT images. For the neck-shaft angle, femoral anteversion, shaft bowing angle, and neck length, the ICCs were 0.812, 0.960, 0.834, and 0.750, respectively, and the mean absolute differences were 2.52°, 2.85°, 0.92°, and 1.88 mm, respectively. Four important dimensions of the femur could be predicted from two views with very good agreement with manual measurements from CT and hip radiographs. The proposed method can help young patients avoid instances of large radiation exposure from CT, and their femoral deformities can be quantified robustly and effectively from one or two radiograph(s).

We report the bone attenuation of ankle joint measured on computed tomography (CT) and the cause of injury in patients with ankle fractures. The results showed age- and gender-dependent low bone attenuation and low-energy trauma in elderly females, which suggest the osteoporotic features of ankle fractures. This study was performed to investigate the osteoporotic features of ankle fracture in terms of bone attenuation and cause of injury. One hundred ninety-four patients (mean age 51.0 years, standard deviation 15.8 years; 98 males and 96 females) with ankle fracture were included. All patients underwent CT examination, and causes of injury (high/low-energy trauma) were recorded. Mean bone attenuations of the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis were measured on CT images. Patients were divided into younger age (

Background Although ankle fracture surgery can affect glycemic control by either trauma-induced stress or a postoperative decrease in physical activity, there is little evidence on this issue. This study aimed to evaluate the influence of ankle fracture surgery on glycemic control and to assess the risk factors for poor glycemic control after surgery in patients with diabetes. Methods We reviewed the medical records of consecutive patients with diabetes who underwent open reduction and internal fixation for the treatment of ankle fracture at our hospital. Patients who underwent blood testing, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and cholesterol levels, as part of a routine check-up before surgery and again more than 2 times after surgery were included. Changes in blood test results were adjusted by multiple factors using a linear mixed model with sex, age at time of surgery, body mass index (BMI), and type of ankle fracture as the fixed effects and each subject and timing of blood test as the random effects. Results Sixty patients were ultimately included in this study. At 1 month postoperatively, mean FBG and cholesterol levels had increased significantly compared with preoperative levels (p = 0.011 and 0.024, respectively). After surgery, FBG levels showed an estimated monthly decrease of 2.2 mg/dL (p = 0.017). Sex, age at time of surgery, and type of ankle fracture did not significantly affect the monthly change in FBG level. FBG returned to the preoperative level at an estimated period of 8.1 months. BMI significantly affected preoperative FBG level (p = 0.015) but not the postoperative change in FBG level (p = 0.500). Conclusion Ankle fracture surgery increased the FBG level at 1 month postoperatively. FBG levels decreased gradually after surgery at an estimated monthly rate of 2.2 mg/dL. Physicians should be aware of the difficulty in postoperative blood glucose control in patients with diabetes, even several months after surgery.

A variety of imidazolium-based ionic liquids (ILs) have been widely developed to effectively catalyze the cycloaddition reactions of CO2 and epoxides. To further improve the catalytic performance of those IL catalysts, we incorporated various metal chlorides (CoCl2, NiCl2, CuCl2, ZnCl2, and MnCl2) into silica-grafted 1-methyl-3-[(triethoxysilyl)propyl] imidazolium chloride to produce a series of heterogeneous catalysts. Catalytic reaction tests demonstrated that the incorporation of such metal ions can significantly enhance the catalytic reactivity of the silica-grafted ILs towards cycloaddition reactions of CO2 and epoxides that produce cyclic carbonates in solvent-free conditions. In addition, the effects on the catalytic reactivity of reaction parameters including reaction time, reaction temperature and CO2 pressure were investigated. We have explored to incorporate various metal chlorides (CoCl2, NiCl2, CuCl2, ZnCl2, and MnCl2) into silica-grafted 1-methyl-3-[(triethoxysilyl)propyl] imidazolium chloride to produce a series of heterogeneous catalysts. Catalytic reaction tests demonstrated that the incorporation of such metal ions can significantly enhance the catalytic reactivity of the silica-grafted ILs towards cycloaddition reactions of CO2 and epoxides that produce cyclic carbonates in solvent-free conditions.

In this study, a series of imidazolium-based ionic liquids (ILs) having carboxylic acid moieties were synthesized and used as new homogeneous catalysts to synthesize cyclic carbonates from CO2 and epoxides. Even in the absence of any co-catalyst and organic solvent, carboxylic-acid-functionalized ILs showed better catalytic activity in the coupling reaction of CO2 and styrene oxide for the production of styrene carbonate than did hydroxyl-functionalized ILs and conventional ILs without any functional moieties. A detailed investigation was carried out on a variety of factors that affected the reactivity, such as the alkyl chain length and the molecular composition of IL molecules including the halide ions. The effect of various reaction parameters such as reaction time, temperature, CO2 pressure and catalyst amount was also investigated in detail. The mechanism underlying the enhanced rate of the cycloaddition reaction in the presence of carboxylic-acid-functionalized ILs was proposed.

Ionic liquids (ILs) immobilized onto a structurally modified Merrifield peptide resin (MPR) were prepared through the reaction of imidazole with alkoxylated MPR. Elemental analysis and scanning electron microscopy (SEM) observations showed that the immobilized IL groups were effectively incorporated on the support. The MPR-supported ILs (MPR-ILs) proved to be effective heterogeneous catalysts for the synthesis of glycerol carbonate (GC) from glycerol and urea. MPR-ILs with longer alkyl chain linkers and fewer sterically hindered counteranions resulted in higher conversion of glycerol. High temperature, high degree of vacuum and the presence of zinc oxide co-catalyst were favorable for glycerol conversion. The MPR-ILs could be reused in up to three consecutive runs without significant loss of their catalytic activity.

Background To compare the clinical and radiological features of intra-/juxta-articular osteoid osteoma and extra-articular osteoid osteoma in skeletally immature patients, paying special attention to the skeletal complications. Methods Osteoid osteoma in 34 children (22 boys and 12 girls, mean age 10.4 years) was dichotomized according to the location of the nidus as intra-/juxta-articular (11 children) or extra-articular (23 children). The following features were compared: diagnostic delay, typical symptoms, synovitis and limited range of joint motion, response to treatment, typical radiographic findings, and skeletal complications. Results Eight of the 11 children with intra-/juxta-articular osteoid osteoma presented with synovitis in the involved joint, which led to a delayed diagnosis for a median 9.5 months. Pain disappeared in all children with surgical or medical interventions, but at the mean 4.9-year follow-up evaluation, skeletal abnormalities around the joint were noted in 5 children (4 proximal femur and 1 distal humerus) with intra-/juxta-articular osteoid osteoma, 2 of whom required subsequent surgeries for limited hip motion caused by femoroacetabular impingement and limited range of elbow motion, respectively. In contrast, typical clinical and radiological features were observed more often in extra-articular osteoid osteoma, and only 1 child showed overgrowth of the tibia, which did not have clinical significance. Conclusions Intra-/juxta-articular osteoid osteomas in growing children exhibit different clinical and radiological features from extra-articular lesions. Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma, and these may lead to permanent skeletal sequelae.

Background: Codman's paradox reveals a misunderstanding of geometry in orthopedic practice. Physicians often encounter situations that cannot be understood intuitively during orthopedic interventions such as corrective osteotomy. Occasionally, unexpected angular or rotational deformity occurs during surgery. This study aimed to draw the attention of orthopedic surgeons toward the concepts of orientation and rotation and demonstrate the potential for unexpected deformity after orthopedic interventions. This study focused on three situations: shoulder arthrodesis, femoral varization derotational osteotomy, and femoral derotation osteotomy. Methods: First, a shoulder model was generated to calculate unexpected rotational deformity to demonstrate Codman's paradox. Second, femoral varization derotational osteotomy was simulated using a cylinder model. Third, a reconstructed femoral model was used to calculate unexpected angular or rotational deformity during femoral derotation osteotomy. Results: Unexpected external rotation was found after forward elevation and abduction of the shoulder joint. In the varization and derotation model, closed-wedge osteotomy and additional derotation resulted in an unexpected extension and valgus deformity, namely, under-correction of coxa valga. After femoral derotational osteotomy, varization and extension of the distal fragment occurred, although the extension was negligible. Conclusions: Surgeons should be aware of unexpected angular deformity after surgical procedure involving bony areas. The degree of deformity differs depending on the context of the surgical procedure. However, this study reveals that notable deformities can be expected during orthopedic procedures such as femoral varization derotational osteotomy.

Background Multiple epiphyseal dysplasia (MED) is a relatively common skeletal dysplasia mainly involving the epiphyses of the long bones. However, it is a genetically heterogeneous group of diseases sharing certain aspects of the radiologic phenotype. In surveys conducted in East Asia, MATN3 was the most common causative gene, followed by COMP. In this study, the authors compared clinical manifestation of MED patients caused by MATN3 and COMP gene mutations, as well as subsequent orthopaedic interventions. Methods Fifty nine molecularly-confirmed MED patients were subjects of this study. The MATN3 gene mutation group comprised of 37 patients (9 female, 28 male). The COMP gene mutation consisted of 22 cases (15 females, 7 males). Medical records and radiographs were reviewed, and questionnaire surveys or telephone interviews were conducted. Results At the first presentation, the mean age was 8.8 ± 2.8 years (mean ± standard deviation) in the MATN3 group, and 8.5 ± 3.5 years in the COMP group (p = 0.670). The height in the COMP group was significantly shorter than those in the MATN3 group (p

Infantile cortical hyperostosis (ICH) is characterized by spontaneous episodes of subperiosteal new bone formation in the long bones, mandible, and clavicle during infancy. A heterozygous missense mutation, c.3040CT (p.R1014C), in the type I collagen alpha1 chain gene (COL1A1) was reported in families with the autosomal dominant form of ICH. We examined six consecutive cases of ICH from five unrelated families and their parents. The mutation was identified in all patients and two parents tested. Our result supported that ICH is caused by the single mutation in COL1A1 with incomplete penetrance.

Background This study was performed to investigate the usefulness of clinical pathway (CP) using an electronic medical record (EMR) in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus, by analyzing the length of hospital stay, hospital cost and satisfaction of the medical teams. Methods This before and after comparative study included consecutive children who underwent closed pinning for supracondylar fracture of the humerus since 2009. The pre-CP group consists of 90 patients with the mean age of 5.7 years, and the post-CP group consists of 32 patients with the mean age of 6.2 years. Multidisciplinary work-team developed CP using an EMR system in March 2011. The length of hospital stay was the primary outcome variable, and hospital cost and medical team’s satisfaction score were secondary outcome variables. The non-inferiority test was used to demonstrate the efficiency of the pathway. Results The length of hospital stay decreased from 2.9 ± 0.7 days to 2.4 ± 0.7 days by 15.0%, after the implementation of CP, and the lower bound of the 95% CI of the difference (0.14 day) was within the non-inferiority margin of −0.3 days. The hospital cost decreased from 1162.2 ± 236.7 US$ to 1139.8 ± 291.1 US$ by 1.9% and the lower bound of the 95% CI of the difference was −81.3 US$, which did not exceed the non-inferiority margin of −116.2 US$. Therefore, the post-CP group was not inferior compared with the pre-CP group in term of the length of hospital stay and total hospital cost. There was significant increase in the satisfaction score for doctors after implementation of CP (p Conclusions The development and implementation of CP, using an EMR, in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus enhances the treatment efficiency by streamlining the treatment process with no increases of the length of the hospital stay and total hospital costs.

Background The purpose of this study was to analyze kinematic trunk motion data in normal adults and to investigate gender effect. Methods Kinematic trunk motion data were obtained for 20 healthy subjects (11 men and 9 women; age from 21 to 40 years) during walking a 9 m long lane at a self selected speed, namely, motions in the sagittal (tilt), coronal (obliquity), and transverse (rotation) planes, which were all expressed as motions in global (relative to the ground) and those in pelvic reference frame (relative to pelvis), i.e., tilt (G), obliquity (G), rotation (G), tilt (P), obliquity (P), rotation (P). Results Range of tilt (G), obliquity (G) and rotation (G) showed smaller motion than that of tilt (P), obliquity (P) and rotation (P), respectively. When genders were compared, female trunks showed a 5 degree more extended posture during gait than male trunks (p = 0.002), which appeared to be caused by different lumbar lordosis. Ranges of coronal and transverse plane motion appeared to be correlated. In gait cycle, the trunk motion appeared to counterbalance the lower extremity during swing phase in sagittal plane, and to reduce the angular velocity toward the contralateral side immediate before the contralateral heel strike in the coronal plane. Conclusions Men and women showed different lumbar lordosis during normal gait, which might be partly responsible for the different prevalence of lumbar diseases between genders. However, this needs further investigation.