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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.

This study evaluated the rates and annual trends of pediatric CT scans in South Korea using a nationwide population-based database.Data regarding pediatric CT scan usage between 2012 and 2017 were retrieved from the health insurance review and assessment service. Data on the age, sex, diagnosis, and the anatomical area of involved patients were also extracted.A total of 576376 CT examinations were performed among 58527528 children aged below 18 years (9.8 scans/1000 children), and the number of CT examinations per 1000 children was noted to have increased by 23.2% from 9.0 in 2012 to 11.0 in 2017. Specifically, the number of CT examinations increased by 32.9% for the 6-12 years of age group (7.4/1000 to 9.8/1000) and by 34.0% for the 13-18 years of age group (11.4/1000 to 15.3/1000). Moreover, majority of the CT scans were limited to the head (39.1%), followed by the extremities (32.5%) and the abdomen (13.7%). Notably, the number of extremity CT scans increased by 83.6% (2.3/1000 to 4.2/1000), and its proportion as compared to other scans increased from 25.3% to 37.7%.CT scans in the pediatric population increased continuously from 2012 to 2017 at an annual rate of 4.4%. Therefore, physicians should balance the benefits of CT with its potential harms from associated radiation exposure in pediatric patients.본 연구는 전국 인구 기반 데이터베이스를 이용하여 국내 소아 전산화단층촬영의 비율과 연간 추세를 평가하였다.2012년부터 2017년까지 국내에서 촬영된 소아 전산화단층촬영에 대한 건강보험 심사평가원의 데이터를 사용하였다. 연령, 성별, 진단명 및 해부학적 위치에 대한 데이터를 같이 추출하여 분석하였다.18세 미만 어린이 58527528명을 대상으로 총 576376건의 전산화단층촬영이 시행되었다(1000명당 9.8회). 어린이 1000명당 전산화단층촬영 횟수는 9.0회에서 11.0회로 23.2% 증가했다. 전산화단층촬영 건수는 6–12세 그룹에서 32.9%(1000명당 7.4회에서 9.8회로 증가), 13–18세 그룹에서 34.0% 증가했다(1000명당 11.4회에서 15.3회로 증가). 부위별 전산화단층촬영의 비율은 두부(39.1%), 사지(32.5%), 복부(13.7%) 순서로 확인되었다. 사지 전산화단층촬영 횟수는 83.6% 증가했으며(1000명당 2.3회에서 4.2회로 증가) 사지 전산화단층촬영의 비율은 25.3%에서 37.7%로 증가했다.소아 환자의 전산화단층촬영은 2012년부터 2017년까지 매년 4.4%의 속도로 지속적으로 증가했다. 따라서 의사는 소아 환자에서 전산화단층촬영으로 인한 이득과 방사선 노출로 인한 잠재적인 피해를 적절히 고려하여 신중하게 촬영을 결정해야 한다.

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.

BackgroundGait deviation and associated torsional problems are common in patients with cerebral palsy (CP). Although femoral anteversion in CP has been extensively reviewed in previous studies, only a few studies have focused on tibial torsion. Therefore, this study aimed to evaluate tibial torsion in patients with CP and investigate the affecting factors.MethodsConsecutive patients with cerebral palsy who underwent 3-dimensional computed tomography for the assessment of rotational profiles were reviewed. Femoral anteversion and tibial torsion were measured, and the demographic characteristics of the patients were recorded. A linear mixed model was implemented to overcome the retrospective nature of the study.ResultsAfter the implementation of inclusion and exclusion criteria, 472 patients were enrolled for this study. With age, external tibial torsion increased, while femoral anteversion decreased. The factors affecting external tibial torsion were increased femoral anteversion (p = 0.0057), increased age (p p p = 0.0471/p = 0.0047).ConclusionsOlder age, GMFCS level IV/V, hemiplegia, and increased femoral anteversion were the independent risk factors of increasedexternaltibial torsion; therefore, performing an imaging study is recommended for assessing the extent of tibial torsion in patients with such characteristics.

Aims Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP. Methods We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement. Results A total of 108 patients were enrolled. The mean preoperative MP was 58.3% (SD 31.7%), which improved to 9.1% (SD 15.6%) at the last follow-up. NSA and MHR improved from 156.5° (SD 11.5°) and 82.3% (SD 8.6%) to 126.0° (SD 18.5°) and 89.1% (SD 9.0%), respectively. Factors affecting the postoperative MHR were preoperative MP (p = 0.005), immediate postoperative MP (p = 0.032), and history of Dega osteotomy (p = 0.046). Conclusion We found that hip sphericity improves with HRS. Preoperative MP, reduction quality, and acetabular coverage influence femoral head remodelling. We recommend that surgeons should consider intervention early before hip displacement progresses and that during HRS, definite reduction and coverage of the femoral head should be obtained. Cite this article: Bone Joint J 2021;103-B(1):198–203.

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.

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.

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

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

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.

Background In order to optimize the tenogenic differentiation of mesenchymal stem cells (MSCs), researchers should consider various factors. However, this requires testing numerous experimental settings, which is costly and time-consuming. We aimed to assess the differential effects of transforming growth factor beta-3 (TGF-β3) on the tenogenesis of tonsil-derived MSCs (T-MSCs) and bone marrow-derived MSCs (BM-MSCs) using response surface methodology (RSM). Methods Bone marrow and tonsillar tissue were collected from four patients; mononuclear cells were separated and treated with 5 or 10 ng/mL of TGF-β3. A full factorial experimental design with a categorical factor of 0 was employed to study the effect of tension based on T-MSCs. Eighty-four trials were fitted with RSM and then used to obtain mathematical prediction models. Results Exposure of T-MSCs and BM-MSCs to TGF-β3 increased the expression of scleraxis (SCX), tenomodulin (TNMD), decorin, collagen I, and tenascin C. Expression of most of these factors reached a maximum after 2–3 days of treatment. The model predicted that the values of the tenocyte lineage-related factors assessed would be significantly increased at 2.5 days of culture with 2.7 ng/mL of TGF-β3 for T-MSCs and at 2.3 days of culture regardless of TGF-β3 concentration for BM-MSCs. Conclusions This study demonstrated that the RSM prediction of the culture time necessary for the tenogenic differentiation of T-MSCs and BM-MSCs under TGF-β3 stimulation was similar to the experimentally determined time of peak expression of tenocyte-related mRNAs, suggesting the potential of using the RSM approach for optimization of the culture protocol for tenogenesis of MSCs.

Background Pathologic gait is common in patients with cerebral palsy (CP). Single-event multilevel surgery (SEMLS) is a combination of surgical procedures to improve pathologic gait in patients with CP. However, the effect of each procedure is difficult to predict. The gait deviation index (GDI) is useful in comparing pre- and postoperative improvement. Research question In this study, we evaluated the degree of GDI improvement in patients with CP and analyzed factors related to surgical outcomes. Methods We screened patients seen between May 2003 and December 2019 via a clinical data warehouse to identify those with CP who had been followed up for >1 year and who had undergone SEMLS. The inclusion criteria were (1) CP patients with GMFCS levels I, II and III, (2) patients who underwent SEMLS, (3) and patients who underwent 3D gait analyses preoperatively and at least 1 year postoperatively. A linear mixed model was used to model GDI improvement, assess effects of covariates, and examine factors that contributed to improvement. Results Overall, 544 patients were included. The average improvement in overall GDI was 8.9 ± 12.3, 9.6 ± 12.0, and 6.4 ± 8.6 in Gross Motor Function Classification System (GMFCS) levels I, II, and III, respectively. In GMFCS level II patients, GDI improvement decreased by 0.26 points with a 1-year delay in surgery (p = 0.0022). Within each group of GMFCS levels, femoral derotation osteotomy (FDO) was a significant factor in GDI improvement in GMFCS levels I and II. Rectus femoris transfer (RFT) and supracondylar extension osteotomy (SCO) were significant factors in GMFCS level II. No single procedure was shown to affect improvement in GMFCS level III. Significance Postoperative GDI improved in all levels of GMFCS. Particular procedures especially affected postoperative improvement in GDI in levels I and II. Our data do not mean to set an indication for particular procedures; however, in GMFCS levels I, II patients, particular procedures, such as FDO, yielded a greater GDI improvement in our data set.

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.

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.

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.

Although papillary thyroid cancers are known to have a relatively low risk of recurrence, several factors are associated with a higher risk of recurrence, such as extrathyroidal extension, nodal metastasis, and BRAF gene mutation. However, predicting disease recurrence and prognosis in patients undergoing thyroidectomy is clinically difficult. To detect new algorithms that predict recurrence, inductive logic programming was used in this study. A total of 785 thyroid cancer patients who underwent bilateral total thyroidectomy and were treated with radioiodine were selected for our study. Of those, 624 (79.5%) cases were used to create algorithms that would detect recurrence. Furthermore, 161 (20.5%) cases were analyzed to validate the created rules. DELMIA Process Rules Discovery was used to conduct the analysis. Of the 624 cases, 43 (6.9%) cases experienced recurrence. Three rules that could predict recurrence were identified, with postoperative thyroglobulin level being the most powerful variable that correlated with recurrence. The rules identified in our study, when applied to the 161 cases for validation, were able to predict 71.4% (10 of 14) of the recurrences. Our study highlights that inductive logic programming could have a useful application in predicting recurrence among thyroid patients.

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.

Background The aim of this study was to provide an analysis of thyroid cancer-related health care costs over a 5-year period, according to the extent of thyroid surgery. Methods The study included 33 patients from our institutional database who underwent thyroid cancer surgery in 2010. Patients were divided into four groups based on surgical extent: (1) hemithyroidectomy, (2) total thyroidectomy, (3) total thyroidectomy with ipsilateral radical neck dissection, and (4) total thyroidectomy with bilateral radical neck dissection and mediastinal dissection. Costs for admission and outpatient follow-up for 5 years were analyzed. Results Costs for outpatient follow-up and admission, and overall cost increased with increasing stage of disease and increasing extent of thyroid surgery. Patients who underwent only hemithyroidectomy had the lowest costs for outpatient follow-up and admission, as well as the lowest overall cost. Conclusion Over the 5-year follow-up period, surgery performed at an early disease stage was the most cost-effective.

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.

Backgroud Single-event multilevel surgery (SEMLS) and hip reconstructive surgery (HRS) often cause intraoperative bleeding, consequently increasing the probability of transfusion and postoperative laboratory changes. Therefore, it is important to assess risk factors to predict the amount of blood loss. This study aimed to evaluate blood loss, its influencing factors, and the related laboratory changes during SEMLS and HRS in patients with cerebral palsy (CP). Methods We retrospectively examined consecutive CP patients who underwent SEMLS and HRS. Surrogate markers of blood loss, including preoperative and postoperative hemoglobin (Hb), hematocrit, and changes in Hb concentration, were assessed. Albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatine levels were also analyzed for related laboratory changes. Risk factors were analyzed using multiple regression and logistic regression models. Results The overall cohort comprised 1,188 patients. Of them, 1,007 and 181 underwent SEMLS and HRS, respectively. Furthermore, 72 of 181 patients underwent a concomitant Dega osteotomy. The regression model showed that low preoperative Hb concentration (p < 0.001), high albumin level (p = 0.007), low body mass index (BMI) (p = 0.002), and bilateral HRS (p < 0.001) were significant risk factors of postoperative anemia. Valproate medication was associated with Hb drop, and the risk factors for Hb level < 8 g/dL on postoperative day 2 were bilateral HRS and Dega osteotomy in the HRS subgroup. In total, 21.6% had elevated AST levels on postoperative day 2, and bilateral HRS (p < 0.001), Gross Motor Function Classification System (GMFCS) level V (p = 0.041), Dega osteotomy (p < 0.001), and high preoperative AST level (p < 0.001) increased the risk of AST elevation. Conclusions We have summarized the estimated blood loss and related laboratory changes after SEMLS and HRS in patients with CP and identified the risk factors. Clinical guidelines should be accordingly developed to include assessment of these risk factors and their impact in the outcomes of CP patients undergoing SEMLS and HRS.

The scattered radiation protector for mobile x-ray systems, Creative Valuable Protector-2, has been recently developed. However, there have been no studies investigating the effects of this device. We aim to investigate the effects of the scattered radiation protector on the equivalent doses from scattered radiation delivered to radiosensitive organs while simulating spine surgery using a C-arm fluoroscope. Chest and rando phantoms were used to simulate a patient and a surgeon in this study. The equivalent dose from scattered radiation to radiosensitive organs was measured in four different situations according to the use of the scattered radiation protector and the C-arm configuration. To compare the quality of the images with and without the scattered radiation protector, an acryl step phantom with five steps was used, and the contrast resolution of each step was calculated. The equivalent dose from the scattered radiation to the surgeon's eye, thyroid, and gonad decreased significantly by using the scattered radiation protector for both the Posteroanterior (PA) (p 0.001) and Anteroposterior (AP) (p 0.001) C-arm configurations. The installation of the scattered radiation protector also reduced the direct radiation dose to the chest phantom. A scattered map showed that scattered radiation doses decreased by approximately 50% for the PA configuration and 75% for the AP configuration by using the scattered radiation protector. Before and after installation of the scattered radiation protector, the contrast resolution of each adjacent step area was 0.025-0.404 and 0.216-0.421. The scattered radiation protector was effective in reducing not only the equivalent dose from scattered radiation to the surgeon's radiosensitive organs, but also the direct radiation dose to the patient. This was all achieved without decreasing the quality of the C-arm fluoroscopic images.

The adequacy of the urologist work force in Korea has never been investigated. This study investigated the geographic distribution of urologists in Korea. County level data from the National Health Insurance Service and National Statistical Office was analyzed in this ecological study. Urologist density was defined by the number of urologists per 100,000 individuals. National patterns of urologist density were mapped graphically at the county level using GIS software. To control the time sequence, regression analysis with fitted line plot was conducted. The difference of distribution of urologist density was analyzed by ANCOVA. Urologists density showed an uneven distribution according to county characteristics (metropolitan cities vs. nonmetropolitan cities vs. rural areas; mean square=102.329, P

Background Precise measuring and monitoring of physical activity (PA) in patients with cerebral palsy (CP) are critical for assessing their PA participation and its potential health benefits. Accelerometer-based assessment of PA has been considered valid, reliable, and practical in children with CP. Therefore, we investigated the correlation between accelerometer- and questionnaire-based assessment of PA in CP patients. Methods Nineteen patients with CP who were classified as Gross Motor Function Classification System level I–III and 84 normally developed participants were included in the study. Study participants wore an accelerometer for seven days, after which they visited the hospital and completed the International Physical Activity Questionnaire (IPAQ). CP patients and their caregivers completed the Pediatric Outcomes Data Collection Instrument (PODCI) and the Caregiver Priorities and Child Health Index of Life with Disabilities, respectively. The concurrent validity of the questionnaires was assessed. Results In the accelerometer-based assessment, time spent in PA was significantly shorter at every intensity level in CP patients than in normally developed participants. However, PA assessed by the IPAQ was significantly higher in patients with CP, indicating that they tend to exaggerate their participation in PA. On the correlation of the assessment by the accelerometer and by the PODCI, transfer/basic mobility, sports/physical function, and happiness increased significantly as the number of steps taken and the distance travelled increased. Conclusions In patients with CP, happiness and quality of life are associated with higher levels of PA. Thus, programs for patients with CP should focus on improving their PA.

Category: Basic Sciences/Biologics Introduction/Purpose: Researchers should consider various potential factors that affect tenogenic differentiation of MSCs. Numerous experimental settings are associated with high cost and time. Response surface methodology (RSM), a component in the design of experiments (DOE), is gaining recognition as a powerful tool in optimizing conditions for the production of industrially important products such as chemicals and enzymes. The purpose of this study was to access the differential effects of transforming growth factor beta 3 (TGF-β3) on the tenogenesis of tonsil-derived mesenchymal stem cells (T-MSCs) and bone marrow-derived mesenchymal stem cells (BM-MSCs) using RSM. Methods: Bone marrow was collected from four patients (mean age: 79.0±2.2) and mononuclear cells were separated. The tonsillar tissues were collected from four patients (mean age: 7.6±0.6). After isolation of MSCs, they were treated with 5ng/ml and 10ng/ml of TGF-β3 with vehicle control. The full-factorial experimental design was employed to study the effect of tension based on T-MSCs. The design was composed of three levels being coded as -1, 0 and +1 and a total of 18 runs were carried out in duplicates to optimize the level of chosen variables, such as days and amount. A total of 84 trials were utilized and fitted with RSM; they were then used to obtain mathematical prediction models. Results: Exposure of TGF-β3 to T-MSCs and BM-MSCs resulted in an increase in the expression of SCX, TNMD, decorin, collagen I, and tenacin C. Most tenocyte lineage-related factors from T-MSCs and BM-MSCs presented a maximum increase in 2- 3 day treatment. Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced at 2.7 ng/mL of TGF-β3 (p < 0.001) on 2.5-day culture (p = 0.001). (Fig A) Considering all of tenocyte lineage-related factors that we assessed, the predicted value of the factors was significantly induced on 2.3-day culture (p = 0.004) regardless of the concentration of TGF-β3. (Fig B) Conclusion: We demonstrated that tenocyte-like cells can be successfully differentiated from T-MSCs and BM-MSCs under TGF- β3 stimulation. This study demonstrated that T-MSCs and BM-MSCs in tenogenic stimulation with TGF-β3 have a similar tenogenic differentiation potential using RSM.

Category: Ankle, Hindfoot Introduction/Purpose: Varus limb malalignment results in an imbalance of force transmission to the knee joint, resulting in a concentrated load in the medial compartment. A varus knee correction may affect the ankle and subtalar joint, because the weight-bearing load on the lower extremity extends from the hip to the foot. A previous study suggested that the true mechanical axis of the lower limb should be calculated with a line from the center of the femoral head to the lowest point of the calcaneus, not to the center of the tibial plafond. Therefore, we performed this study to evaluate changes in the mechanical axis and weight- bearing line of the ankle after varus knee correction. Methods: Patients with a varus knee who were followed-up after they had undergone high tibial osteotomy (HTO) or total knee replacement arthroplasty (TKA) at an age of >20 years, and who had undergone preoperative and postoperative scanogram were included in this study. The hip-knee-ankle (HKA) angle, mechanical axis, and weight-bearing line (line from the center of the femoral head to the lowest point of the calcaneus) were measured on the radiographs. The point at which the mechanical axis and weight-bearing line passed through the tibial plafond was the ankle joint axis point. The postoperative change in the ankle joint axis point on the mechanical axis and weight-bearing line according to the HKA angle correction was adjusted by multiple factors using a linear mixed model. Results: A total of 257 limbs from 198 patients were included in this study. The preoperative HKA was 7.3 ± 4.7° and corrected to 0.4 ± 3.8°. Although the ankle axis points on both axes moved laterally after HTO and TKA, the ankle joint axis of the weight- bearing line showed a significant larger lateral movement (22.5±35.7%) (Fig.) than that of the mechanical axis (15.7±16.0%) in terms of rate of change (p = 0.006). The ankle joint axis point on the weight-bearing line moved laterally by 0.9% per degree of postoperative HKA angle decrease (p < 0.001). The change in the ankle joint axis point on the mechanical axis was not statistically significant after HTO and TKA (p = 0.223). Conclusion: The mechanical axis and weight-bearing line of the ankle moved laterally after the varus knee correction. The ankle joint axis on the weight-bearing line moved laterally as the HKA angle decreased after the surgery, whereas the varus knee correction did not significantly affect the ankle joint axis on the mechanical axis. The varus knee correction might affect the subtalar joint as well as the ankle joint. Therefore, we believe that our findings warrant consideration in pre- and postoperative evaluations using the weight-bearing line of patients undergoing varus knee correction.

Background Concurrent prophylactic femoral varization osteotomy (FVO) for stable hips has been performed in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for the contralateral displaced hip. However, there is currently a lack of studies investigating the outcome after the prophylactic FVO in stable hip. This study investigated the outcomes after FVO in stable hips with CP and influencing factors. In addition, this study compared the outcomes with those after hip reconstructive surgery in the contralateral displaced hip. Methods This study included 119 CP patients with 224 hips (80 stable, 144 displaced) undergoing hip reconstructive surgery including FVO. Migration percentage (MP), neck-shaft angle (NSA), and head-shaft angle (HSA) were measured through preoperative and follow-up hip radiographs. All hips were divided into the stable (MP ≤ 33%) and displaced hip groups (MP > 33%) according to the preoperative radiographs, and the annual changes in the radiographic indices after FVO were analyzed. Results In stable hip group, MP did not significantly increase over time (p = 0.057) after prophylactic FVO. In displaced hip group, MP significantly increased over time (1.6%/year, p

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.

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.

Purpose We aimed to evaluate the nationwide incidence and risk factors for symptomatic deep vein thrombosis (DVT) after major lower limb orthopedic surgeries. Materials and Methods The Korean Health Insurance Review and Assessment Service database was used to retrospectively identify International Classification of Disease-10 codes for DVT and operation codes representing hip arthroplasty, knee arthroplasty, and hip fracture surgeries. The age- and gender-adjusted annual incidence of DVT, rates of major lower limb orthopedic surgeries, and the postoperative incidence of DVT according to the surgical procedure were assessed. Results The age- and gender-adjusted annual incidence of DVT was 70.67 per 100000 persons/year. Compared to patients aged 70 years (p

Osteoporotic fractures in subjects with diabetes mellitus (DM) carry higher mortality and morbidity. Because bone strength and minor trauma, such as a falls, are considered to be significant factors contributing to osteoporotic fractures, it is important to elucidate the associated factors with these.This study was performed to investigate the factors associated with bone mineral density (BMD) and falls in noninstitutionalized subjects with DM aged 50 years or older.We used the database from the 2010 Fifth Korea National Health and Nutrition Examination Survey. Subjects with DM aged 50 years or older were selected and included in the data analyses. Associated factors with BMD of the femoral neck and lumbar spine and those with falls were analyzed using multiple linear regression and binary logistic regression analyses, respectively.Three hundred sixty-two subjects [209 males; 153 females; average age, 66.0 y (SD 8.2 y)] were included. Among the male subjects, the total body muscle mass (P.001), daily calcium intake (P = .001), ALP levels (P = .007), and body mass index (P = .027) were significantly associated with femoral neck BMD, whereas body mass index (P = .001) and ALP levels (P = .040) were associated with lumbar spine BMD. Among the female subjects, age (P.001), daily calcium intake (P = .011) and total body muscle mass (P = .023) were found to be significantly associated factors with femoral neck BMD, whereas age (P.001) and body mass index (P = .012) and daily calcium intake (P = .040) were those with lumbar spine BMD. Osteoarthritis (P = .024) and total body muscle mass (P = .028) were found to be significantly associated with the risk of falls.Total body muscle mass was the most prominent factor predicting femoral neck BMD and risk of falls in community-dwelling elderly subjects with DM. Further investigation is required to determine their role in preventing osteoporotic fractures in diabetic subjects.

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.

Letter to the Editor

Background We performed this study to investigate the influence of recombinant human growth hormone (rhGH) therapy on radiographic indices of the spine using propensity-matched analysis. Methods Patients with idiopathic short stature who had undergone both growth hormone therapy and whole-spine radiographs more than twice prior to 15 years of age were included in the patient group. Other patients who had undergone whole-spine radiographs more than twice prior to the same age during regular checkups for idiopathic scoliosis formed the control group. Propensity-matched analysis was performed to reduce the selection bias. The scoliosis Cobb angle, coronal balance, apical vertebral translation, apical rotation, and pelvic obliquity were measured from the radiographs taken at the periodic follow-ups. The rate of progression of the measurements was adjusted by multiple factors using a linear mixed model with sex as the fixed effect and age and each subject as the random effects. Results Using a propensity-matched analysis, 48 patients were finally included in both groups. The scoliosis Cobb angle increased by 1.0° (p

Category: Ankle, Sports Introduction/Purpose: We hypothesized that the bony configuration of the ankle could also be associated with ankle stress radiographs, in addition to ligament injury of the ankle. Therefore, this study aimed to investigate the relationship between bone morphology and injured ligament on imaging studies and laxity on ankle stress radiographs in patients with lateral ankle instability. Methods: In total, 115 patients who had undergone ankle MRI, ankle radiography, and stress radiography were included. Distal tibial articular surface angle, bimalleolar tilt, medial and lateral malleolar relative length, medial malleolar slip angle, anterior inclination of the tibia, and fibular position were measured on ankle radiographs. Tibiotalar tilt angle and anterior translation of the talus were measured on ankle stress radiographs. Degree of ligament injury was evaluated on ankle MRIs. Multiple regression analysis was performed using the following independent variables: age, sex, and factors significantly associated with ankle stress view on univariate linear regression analysis. Results: Age (p = 0.041), sex (p = 0.014), degree of anterior talofibular ligament injury (p < 0.001), and bimalleolar tilt (p = 0.016) were correlated with tibiotalar tilt angle (Table). Younger patients demonstrated a larger tibiotalar tilt angle than older patients, and the angle decreased by 0.07° per year of age. Tibiotalar tilt angle in female patients was 2.2° larger than that in male patients. Fibular position and degree of posterior talofibular ligament injury were factors significantly related to anterior translation of the talus. Conclusion: Differences in patient characteristics might predispose ankle stress radiograph results. Comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side, in order to reduce the influence of patient factors.

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.

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.

To identify the incidence and risk factors of macular edema development following single-session pattern scan laser panretinal photocoagulation (PRP) for eyes with diabetic retinopathy.Medical records were reviewed in consecutive patients who underwent single-session PRP for diabetic retinopathy. The eyes with baseline central subfield retinal thickness (CRT) less than 300 μm were included.Macular edema developed in 11 (8.5%) of 129 eyes 1 months after PRP. In the multivariate analysis, baseline CRT (μm) (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.00-1.08, p = 0.048) and presence of intraretinal cystoid spaces or subretinal fluid on spectral-domain optical coherence tomography (SD-OCT) images (OR = 38.33; 95% CI = 1.36-1,083.14, p = 0.032) were significantly associated with macular edema development at 1-month visit. Macular edema developed in two (2.1%) of 97 eyes without cystoid spaces or subretinal fluid. The macular edema was spontaneously resolved in five (45.5%) of 11 cases at 3-month visit.SD-OCT may be helpful in predicting the development of macular edema, although the macular edema rarely developed after single-session pattern scan laser PRP and was spontaneously resolved in many cases.

Objectives To evaluate the impact of obesity on the biopsy detection of prostate cancer. Methods We retrospectively reviewed data of 1182 consecutive Korean patients (≥50 years) with serum prostate-specific antigen levels of 3–10 ng/mL who underwent initial extended 12-cores biopsy from September 2009 to March 2013. Patients who took medications that were likely to influence the prostate-specific antigen level were excluded. Receiver operating characteristic curves were plotted for prostate-specific antigen and prostate-specific antigen density predicting cancer status among non-obese and obese men. Results A total of 1062 patients (mean age 67.1 years) were enrolled in the analysis. A total of 230 men (21.7%) had a positive biopsy. In the overall study sample, the area under the receiver operator characteristic curve of serum prostate-specific antigen for predicting prostate cancer on biopsy were 0.584 and 0.633 for non-obese and obese men, respectively (P = 0.234). However, the area under the curve for prostate-specific antigen density in predicting cancer status showed a significant difference (non-obese 0.696, obese 0.784; P = 0.017). Conclusions There seems to be a significant difference in the ability of prostate-specific antigen density to predict biopsy results between non-obese and obese men. Obesity positively influenced the overall ability of prostate-specific antigen density to predict prostate cancer.

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.

The burden of herpes zoster may be related to patients' immunity, although this has not been studied extensively. This hypothesis was tested in a matched case-control study of patients with herpes zoster who sought treatment at one of seven university hospitals in Korea from January 1, 2007, to December 31, 2010. Patients diagnosed with herpes zoster were placed into three groups based on their immune status: severely immunocompromised, mild-to-moderately immunocompromised, and normal immunity. Each patient in the severely immunocompromised group was matched with one patient in the mild-to-moderately immunocompromised group and one patient in the normal immunity group in the same hospital based on age, sex, and date of herpes zoster onset. A total of 582 patients with herpes zoster were included in the analysis: 194 in each of the three groups. Patients in the severely immunocompromised group had the highest herpes zoster-related hospitalization rate as compared to patients in the mild-to-moderately immunocompromised and normal immune groups (P < 0.01). The length of hospital stay and herpes zoster-related medical cost increased significantly with the deterioration of patients' immunity (P < 0.01, respectively). Cutaneous complications occurred more frequently in the severely immunocompromised group than in the other two groups (P < 0.01). An increase in herpes zoster burden was observed as the patients' immunity decreased. Therefore, effective measures are necessary to prevent herpes zoster and reduce its burden in severely immunocompromised patients.

This study aims to investigate the real indications for low-dose tamsulosin monotherapy for initial treatment. A cross-sectional study was conducted in a total of 1643 patients with lower urinary tract symptoms (LUTS) and with initial low-dose tamsulosin. Initial pretreatment data including the International Prostate Symptoms Score (IPSS), prostate volume, and uroflowmetry data were reviewed. After 8 weeks of treatment, post-treatment IPSS and satisfaction was assessed. Logistic regression analysis was conducted to investigate the pretreatment factors influencing post-treatment satisfaction. Overall satisfaction rate with low-dose tamsulosin as an initial treatment medication was 88.7%. Multivariate analysis revealed that symptom durations, IPSS voiding score, IPSS storage score, and quality of life (QoL) were determinant factors for patient satisfaction. ROC analysis revealed that a urinary score > 10 and symptom duration > 3 years showed satisfaction with a sensitivity of 85.8% and 90.6%, respectively, and specificity of 43.5% and 39.8%, respectively. Whereas, ROC analysis revealed that a storage score > 5 and QoL > 3 showed nonsatisfaction with sensitivity of 84.2% and 39.5%, respectively, and specificity of 43.5% and 45.7%, respectively. Multivariate regression analysis demonstrated that voiding score and storage score had a significant relationship with QoL (unstandardized coefficients: 0.073, 0.145, respectively; P-value