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Radiographic factors estimate the state of the static knee joint, and it is questionable how well these parameters reflect the dynamic knee condition. The external knee adduction moment (KAM) during gait is known to be a kinetic variable contributing to osteoarthritis progression. This study aims to investigate the effects of static radiographic parameters on the dynamic KAM during gait.Overall, 123 patients (mean age, 65.7 years; standard deviation, 8.1 years; 34 men and 89 women) were included. Seven radiographic parameters including the mechanical tibiofemoral angle (mTFA), Kellgren-Lawrence grade, and ankle joint line orientation (AJLO) were measured on radiographs, and the maximum KAM and KAM-time integral in the stance phase were obtained using three-dimensional gait analysis. The correlation and multiple regression analyses were performed for identifying significant radiographic measurements associated with the KAM.Most of the radiographic measurements correlated with the maximum KAM and KAM-time integral. As a result of multiple regression analysis, the mTFA (p 0.001) and AJLO (p = 0.003) were identified as significant factors associated with the KAM-time integral (RThe mTFA and AJLO were significantly associated with the KAM. However, to be used as a surgical indication for corrective osteotomy, a longitudinal study is needed to validate whether the mTFA and AJLO values directly cause osteoarthritis progression as we have suggested.III.

Background This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity. Methods Consecutive 97 patients (150 feet; mean age 10 years; range 5.1–35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model. Results There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (− 5.0°, p = 0.034) than those with idiopathic cause. Conclusion This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study’s findings when planning operative treatment for such patients.

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.

Chondrosarcomas, malignant cartilaginous neoplasms, are capable of transitioning to highly aggressive, metastatic, and treatment-refractory states, resulting in significant patient mortality. Here, we aim to uncover the transcriptional program directing such tumor progression in chondrosarcomas. We conduct weighted correlation network analysis to extract a characteristic gene module underlying chondrosarcoma malignancy. Hypoxia-inducible factor-2α (HIF-2α, encoded by EPAS1) is identified as an upstream regulator that governs the malignancy gene module. HIF-2α is upregulated in high-grade chondrosarcoma biopsies and EPAS1 gene amplification is associated with poor prognosis in chondrosarcoma patients. Using tumor xenograft mouse models, we demonstrate that HIF-2α confers chondrosarcomas the capacities required for tumor growth, local invasion, and metastasis. Meanwhile, pharmacological inhibition of HIF-2α, in conjunction with the chemotherapy agents, synergistically enhances chondrosarcoma cell apoptosis and abolishes malignant signatures of chondrosarcoma in mice. We expect that our insights into the pathogenesis of chondrosarcoma will provide guidelines for the development of molecular targeted therapeutics for chondrosarcoma., Chondrosarcomas are frequently aggressive, understanding the transcriptional changes associated with progression may help in developing new treatments. Here, the authors show that HIF-2α is increased in expression on progression and pharmacological inhibition of the protein together with chemotherapy is a useful strategy for controlling tumour growth in mice.

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 The purpose of this study was to translate and transculturally adapt the original English version of the Oxford Ankle Foot Questionnaire (OAFQ) into a Korean version, and to evaluate its psychometric properties. Methods A Korean OAFQ for children was developed according to established guidelines. To test validity, 169 consecutive patients with foot and ankle problems and their caregivers each completed the OAFQ. The children also completed a Korean version of the KIDSCREEN-52 health related quality of life questionnaire (KIDSCREEN-52 HRQOL). To validate the Korean version of the OAFQ, reliability (child–parent agreement and internal consistency), feasibility (floor and ceiling effects), and construct validity were evaluated, and factor analysis was performed. Results In terms of reliability, Cronbach’s α values were > 0.7 in all subscales of the OAFQ (0.765 to 0.901). Child–parent agreement was confirmed by high intraclass correlation coefficients for all subscales (0.791 to 0.863). In terms of construct validity, there were moderate correlations between the subscales of the OAFQ and the subscales of the KIDSCREEN-52 HRQOL. Factor analysis revealed a three-component solution for both the child/adolescent and parent-proxy version, by combining the school and play, and footwear items into one subscale. In terms of feasibility, no floor effects were found for all subscales. However, ceiling effects were observed for the school and play, and emotional subscales for child/adolescent and parent-proxy versions. Conclusions The OAFQ was successfully translated and transculturally adapted into the Korean language; the Korean version of the OAFQ represents a reliable and valid instrument for evaluating children’s foot or ankle problems. However, factor analysis suggested the use of a three-subscale questionnaire.

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.

Background Gait disturbances, including flexed knee gait, stiff knee gait, and tip-toeing gait, are common in patients with cerebral palsy (CP). There has been no reports regarding kinematic changes in the transverse plane after soft tissue surgeries, such as distal hamstring lengthening (DHL), rectus femoris transfer (RFT), and tendo-Achilles lengthening (TAL). This study aimed to evaluate changes in the transverse plane after soft tissue surgery in patients with CP by assessing the effects of the DHL, RFT, and TAL. Methods The study enrolled 156 consecutive patients (mean age, 8.4 years; range, 4.4 to 20.9), representing 213 operated limbs, who underwent soft tissue surgery including DHL with semitendinosus transfer, RFT, and TAL. All patients were assessed by preoperative and 1-year postoperative three-dimensional gait analysis. Changes in transverse plane kinematics after soft tissue surgery and affecting factors were analyzed. Results Sagittal kinematics including knee flexion at initial contact, ankle dorsiflexion at initial contact, and mean ankle dorsiflexion in the stance phase were significantly improved after single event multilevel surgery (all p p = 0.004 and − 9.5°, p p = 0.010) and the foot progression angle was significantly improved to a more external angle by TAL (− 3.9°, p = 0.028). Conclusions This study found that the transverse kinematics were improved to a more external angle after soft tissue surgery in patients with CP. Therefore, clinicians should consider that soft tissue surgery can affect the transverse plane kinematics in patients with CP. To confirm our findings, further research regarding the natural history of femoral and tibial torsion in children with CP is needed.

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

Plantar fasciitis is a common cause of heel pain affecting 10% of the general population. This study aimed to investigate the specific symptoms in patients with plantar fasciitis using the Foot and Ankle Outcome Score (FAOS) questionnaire and their relationship with demographic and radiographic factors.We retrospectively analyzed 73 consecutive patients (mean age, 53.8 ± 10.0 years; 20 men and 53 women) with plantar fasciitis who had visited our foot and ankle clinic and undergone weight-bearing foot X-ray examinations. Their demographic data, anteroposterior and lateral talo-first metatarsal angles, intermetatarsal and hallux valgus angles, and responses to the FAOS questionnaire were recorded.The quality-of-life subscale showed the lowest score of all FAOS subscales. Age was significantly correlated with quality of life (Demographic factors were associated with specific symptoms in patients with plantar fasciitis. Calcaneal spur size was the only radiographic parameter correlated with symptoms. These findings help communicate with patients, set appropriate treatment goals, and evaluate treatment effectiveness.

We compared the central retinal vascular trunk (CRVT) position, as a surrogate of lamina cribrosa (LC) offset, with the anterior scleral opening (ASCO) offset from the Bruch’s membrane opening (BMO). Based on the BMO-centered radial scans, the BMO and ASCO margins were demarcated, and each center was determined as the center of the best-fitted ellipse for each margin. The ASCO/BMO offset was defined as the offset between each center. Angular deviations and the extent of ASCO and CRVT offsets from the BMO center were compared directly. Incomplete demarcation of ASCO was found in 20%, which was associated with a larger BMO area and a larger ASCO offset from the BMO. The angular deviation of ASCO offset was associated with that of CRVT offset and that of the longest externally oblique border. The ASCO offset was smaller than the CRVT offset, and, unlike the CRVT offset, it was rarely deviated to the inferior side. The complete ASCO margin might not be demarcateable when determined on BMO-centered radial scans in the presence of an offset. Also, the ASCO, which reflects only the superficial scleral layer, might not reflect the LC position, because the LC might be shifted further from the ASCO.

We report the case of a pediatric patient with Ewing’s sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.

Background Kinetic data obtained during gait can be used to clarify the biomechanical pathogenesis of osteoarthritis of the lower extremity. This study aimed to investigate the difference in ankle varus moment between the varus angulation and medial translation types of medial ankle osteoarthritis, and to identify the radiographic measurements associated with ankle varus moment. Methods Twenty-four consecutive patients [mean age 65.8 (SD) 8.0 years; 9 men and 15 women] with medial ankle osteoarthritis were included. Fourteen and 10 patients had the varus angulation (tibiotalar tilt angle≥3 degrees) and medial translation (tibiotalar tilt angle Results The mean tibial plafond inclination, tibiotalar tilt angle, talar dome inclination, lateral talo-first metatarsal angle, and maximum ankle varus moment were 6.4 degrees (SD 3.3 degrees), 5.0 degrees (SD 4.6 degrees), 11.4 degrees (SD 5.2 degrees), -6.5 degrees (SD 11.7 degrees), and 0.185 (SD 0.082) Nm/kg, respectively. The varus angulation type showed a greater maximum ankle varus moment than the medial translation type (p = .005). The lateral talo-first metatarsal angle was significantly associated with the maximum ankle varus moment (p = .041) in the multiple regression analysis. Conclusion The varus angulation type of medial ankle osteoarthritis is considered to be more imbalanced biomechanically than the medial displacement type. The lateral talo-first metatarsal angle, being significantly associated with the ankle varus moment, should be considered for correction during motion-preserving surgeries for medial ankle osteoarthritis to restore the biomechanical balance of the ankle.

Scrambler therapy is a noninvasive electroanalgesia technique designed to remodulate the pain system. Despite growing evidence of its efficacy in patients with neuropathic pain, little is known about the clinical factors associated with treatment outcome. We conducted a prospective, open-label, single-arm trial to assess the efficacy and safety of scrambler therapy in patients with chronic neuropathic pain of various etiologies. A post-hoc analysis was performed to investigate whether cluster analysis of the Neuropathic Pain Symptom Inventory (NPSI) profiles could identify a subgroup of patients regarding neuropathic pain phenotype and treatment outcome. Scrambler therapy resulted in a significant decrease in the pain numerical rating scale (NRS) score over 2 weeks of treatment (least squares mean of percentage change from baseline, − 15%; 95% CI − 28% to − 2.4%; p

Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). We hypothesized that os subfibulare could interrupt the talofibular space causing impingement, resulting in chronic pain and functional instability around the lateral malleolus. The purposes of this study were to analyze morphologic characteristics of os subfibulare, and to evaluate the clinical significance of the os subfibulare in patients with CLAI. Methods: Between November 2011 and April 2015, 70 patients who had both computed tomography (CT) and magnetic resonance imaging (MRI) among 252 patients who visited our hospital with the symptom of lateral ankle instability were included in this study. The location of the ossicle was classified into 3 zones in reference to the attachment site of the lateral ankle ligaments. The impingement was classified into 2 groups according to the presence of talofibular encroachment. Digital radiographs were used to measure the ossicle width and shape determined by the length and width on an magnetic resonance (MR) image. Results: The most common shape of ossicles was oval, and the most common location of ossicles was at the anterior talofibular ligament (ATFL) attachment site. Sixty-one percent of patients showed talofibular impingement on coronal MR images. In 48 cases, the dimension of fibula plus os subfibulare was larger than that of the contralateral normal fibula. The larger size and talofibular impingement of the ossicle were associated with greater need for operative treatment in patients with ankle instability. Conclusion: The morphologic analysis of the os subfibulare revealed that there might be impingement of the talofibular space by the ossicle in some patients. We suggest that morphologic characteristics of the os subfibulare should be considered when selecting treatment options in patients with CLAI and os subfibulare. Level of Evidence: Level III, retrospective comparative series.

Although many radiographic measurements of the foot and ankle have been used, reference values for normal functional groups are rarely reported. These can change according to sex and age; therefore, this study aimed to: (1) determine reference values for radiographic foot and ankle angles in an asymptomatic healthy Korean population, and (2) compare differences in the measurements according to sex and age. A total of 200 healthy volunteers were recruited, including 100 young adults (50 males, 50 females) aged 20 to 35 years, and 100 older adults (50 males, 50 females) aged 60 to 69 years. Weightbearing ankle anteroposterior views, talar tilt, and tibiotalar angles were measured. On the weightbearing foot anteroposterior views, the hallux valgus, hallux interphalangeal, and talo-first metatarsal angles were measured. On the weightbearing lateral foot views, the calcaneal pitch, lateral talo-calcaneal, lateral talo-first metatarsal, and lateral calcaneo-first metatarsal angles were measured. Values were stratified by sex and age, and statistically compared. The hallux valgus, calcaneal pitch, and lateral calcaneo-first metatarsal angles were affected by both sex and age; the hallux interphalangeal angle was affected by age and the lateral talo-first metatarsal angle by sex. We presented reference values for foot and ankle radiographic measurements in a healthy Korean population; several radiographic indices varied significantly by sex or age, which were grossly similar to previous studies based on white race. The study data can serve as a basis for evaluation of foot and ankle disorders.

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 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

Objectives Motion preserving surgeries could be unsuccessful because of underestimation of deformities of the foot and knee in ankle osteoarthritis. This study aimed to investigate the concomitant deformities in medial ankle osteoarthritis and the difference between the two types, varus angulation and medial translation. Methods A retrospective study was conducted using medical records and radiographic data. Patients with medial ankle osteoarthritis that underwent weight-bearing X ray imaging and radiographic measurements including tibial plafond inclination (TPI), tibiotalar tilt angle (TT), lateral talo-first metatarsal angle, naviculo-cuboid overlap, and mechanical tibiofemoral angle (mTFA) were studied. The patients were categorized into two groups, the varus angulation group (TT ≥4°) and medial translation group (TT Results A total of 102 patients (male = 44; female = 58) were included; the mean age was 64.9 years (SD 8.3 years). The varus rotation group (N = 66) showed a significantly smaller lateral talo-first metatarsal angle (p Conclusions Varus angulation of the ankle was correlated with knee alignment and foot deformity. Radiographic indices were different between the varus angulation and medial translation groups. The role of concomitant deformities needs to be further investigated in terms of a causal relationship. Surgeons need to pay attention to concomitant deformities in the treatment of medial ankle osteoarthritis.

Situs inversus of optic disc (SIOD) is thought to be a congenital optic disc abnormality that is caused by dysversion of optic nerve insertion. SIOD, however, has many additional features that cannot be explained by abnormal optic-nerve-insertion directionality. In this study, we measured the distance between the fovea and disc in 22 eyes of 15 SIOD patients. For comparison, two control eyes were matched with each SIOD eye by age and axial length. The vertical distance between the temporal vascular arcades also was measured. The foveo-disc distance was shorter in the SIOD eyes than in the control eyes, while the inter-arcade distance did not differ. Further, we measured the circumpapillary retinal nerve fiber layer thickness, which showed nasal crowding of two humps in the SIOD eyes. This nasal crowding disappeared when we shifted the circle scan by the mean difference (465 μm) of the foveal-disc distance between the two groups. Our findings suggest that the optic disc was located closer to the fovea than it would have been normally. Thus, SIOD might reflect incomplete expansion of the posterior pole in the direction of the fovea-disc axis.

Purpose To compare retinal nerve fiber layer (RNFL) defects' angle measurements determined from the center of the optic disc and Bruch's membrane opening (BMO), as a function of myopia and open-angle glaucoma (OAG) subtypes. Methods In total, 118 patients with OAG were grouped by axial length (AL; high myopia, AL >26 mm; mild to moderate myopia, 24 ≤ AL ≤26 mm; nonmyopia, AL

Purpose To investigate whether the position of the central vascular trunk, as a surrogate of lamina cribrosa (LC) shift, is associated with the initial hemisphere of visual field defect in myopic high-tension glaucoma (HTG) eyes. Methods The deviation of the central vascular trunk was measured from the center of the Bruch’s membrane opening (BMO), which was delineated by OCT imaging. The angular deviation was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The initial hemisphere developing visual field defect was defined as three connected abnormal points (having a P value with less than 0.5% probability of being normal) appearing in only one hemisphere in pattern deviation plots. If those points were observed in both hemispheres initially, the eye was classified as bi-hemispheric visual field defect. Results Initially, 36 eyes (44%) had superior visual field defects, 27 (33%) inferior visual field defects, and 18 (22%) bi-hemispheric visual field defects. After a mean follow-up of 5 years, the number of bi-hemispheric visual field defects had increased to 34 (42%). A logistic regression analysis revealed that inferior deviation of vascular trunk was the only factor associated with initial inferior visual field defect (P = 0.001), while initial bi-hemispheric visual field defects were associated with worse mean deviation at initial visits (P

Background This study aimed to investigate the change in ankle varus incongruencies following total knee replacement (TKR) in patients with preoperative genu varum deformity of ≥10°. Methods The study cohort was composed of patients who underwent TKR in a single institution for knee osteoarthritis with preoperative genu varum deformity of ≥10° and concomitant varus ankle incongruencies. Eight radiographic measurements were evaluated preoperatively and postoperatively: mechanical tibiofemoral angle, mechanical lateral distal femoral angle, medial proximal tibial angle, lateral distal tibial angle, tibial plafond inclination, talar inclination, tibiotalar tilt angle (TTTA), and tibia-mechanical axis angle. Of these, TTTA represented the quantitative degree of ankle joint incongruency. Results A total of 110 patients (male = 2; female = 108) were included in the analysis. The mean patient age was 68.9 (standard deviation [SD] 7.2) years at the time of TKR. All radiographic measurements showed significant changes postoperatively, representing the appropriate correction of genu varum deformity and restoration of the mechanical axis. Nineteen patients (17.3%) showed postoperative decrease in TTTA, 2 (1.8%) remained the same, and 89 (80.9%) showed increase. Overall, mean preoperative and postoperative TTTA were 3.3° (SD 2.2°) and 4.7° (SD 2.9°), respectively (P Conclusion Varus ankle incongruencies showed aggravation following TKR despite correction of genu varum deformity and restoration of the mechanical axis. This could be an important cause of postoperative increase or development of ankle pain following TKR. Therefore, patients with preoperative varus ankle incongruencies need to be warned of possible aggravation of ankle symptoms and be evaluated before TKR. Level of Evidence Prognostic level III.

Background In planovalgus deformity with triceps contracture, a midfoot break happens, and ankle dorsiflexion (ADF) occurs at the mid-tarsal joint during gait. Results of standard 3D gait analysis may misinterpret the true ankle dorsiflexion because it recognizes the entire foot as a single rigid segment. We performed this study to investigate whether the severity of planovalgus deformity is associated with the discrepancy between the value of ADF evaluated by physical examination and 3-dimensional (3D) gait analysis. In addition, we aimed to identify the radiographic parameters associated with this discrepancy and their relationships. Methods Consecutive 40 patients with 65 limbs (mean age, 11.7 ± 5.5 years) with planovalgus foot deformity and triceps surae contracture were included. All patients underwent 3D gait analysis, and weightbearing anteroposterior (AP) and lateral (LAT) foot radiographs. ADF with knee extension was measured using a goniometer with the patient’s foot in an inverted position. Results Twenty-one limbs underwent operation for planovalgus foot deformity, and 56 limbs underwent operation for equinus deformity. The difference between ADF on physical examination and ADF at initial contact on gait analysis was 17.5 ± 8.4°. Differences between ADF on physical examination and ADF at initial contact on gait analysis were significantly associated with the LAT talus-first metatarsal angle (p = 0.008) and calcaneal pitch angle (p = 0.006), but not associated with the AP talus-first metatarsal angle (p = 0.113), talonavicular coverage angle (p = 0.190), talocalcaneal angle (p = 0.946), and naviculocuboid overlap (p = 0.136). Conclusion The discrepancy between ADF on physical examination and 3D gait analysis was associated with the severity of planovalgus deformity, which was evaluated on weightbearing LAT foot radiographs. Therefore, physicians should be cautious about interpreting results from 3D gait analysis and perform a careful physical examination to assess the degree of equinus deformity in patients with planovalgus foot deformity.

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.

To build an appropriate strategy of pain management after ankle fracture surgery, surgeons need to know the characteristics of postoperative ankle pain and its contributing factors. The aim of the present study was to investigate the maximum pain period after ankle fracture surgery and the factors affecting postoperative pain using a linear mixed model when patient-controlled analgesia (PCA) was used as a basic modality. A total of 219 adult patients (108 males and 111 females; mean age 51.2 ± 15.9 years) who had undergone operative treatment for ankle fractures were included. Data on fracture severity, causes of injury, interval between injury and surgery, anesthesia method, American Society of Anesthesiologists classification, and operative time were collected. Pain intensity was measured using an 11-point pain intensity numerical rating scale preoperatively and postoperatively every 8 hours. Intravenous PCA was prescribed to all patients. The chronologic pattern of postoperative pain and factors affecting it were statistically analyzed using a linear mixed model. Maximum postoperative pain was observed at 8 hours postoperatively, and the maximum pain numerical rating scale score was 3.92, measured at 8-hour intervals. The severity of fracture ( p = .01) was the only significant factor contributing to postoperative pain after ankle fracture surgery on multivariate analysis. Clinicians should consider the chronologic pattern of postoperative pain after ankle fracture surgery during postoperative pain management. Interventions for pain control, in addition to PCA, might be needed at ~8 hours postoperatively, especially for those with severe ankle fractures.

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.

The aim of this study was to find the optimal table height to facilitate insertion of the spinal needle at a 90° angle and to reduce the anesthesiologist's discomfort. Sixty patients were randomly allocated according to landmarks on the anesthesiologist's body: umbilicus (group U), lowest rib margin (R), xiphoid process (X), and nipple (N). The coronal insertion angle between the patient's skin and the spinal needle was obtuse in groups U and R, and 90° in group X. We demonstrated that high operating tables at the xiphoid and nipple level facilitate more optimal needle entry angles while reducing the discomfort and joint flexion of anesthesiologists during spinal anesthesia.

BACKGROUND Semantic variant primary progressive aphasia (svPPA) has been associated with a variety of proteinopathies, mainly transactive response DNA-binding protein, but also with tau and β-amyloid. Recently selective tau tracers for positron emission tomography (PET) have been developed to determine the presence of cerebral tau deposits in vivo. Here, we investigated the topographical distribution of THK5351 in svPPA patients. MATERIALS AND METHODS Five svPPA patients, 14 Alzheimer's disease patients, and 15 age-matched normal controls underwent [F]-THK5351 PET scans, magnetic resonance imaging, and detailed neuropsychological tests. [F]-fluorodeoxyglucose PET was obtained in 3 svPPA patients, whereas the remaining 2 underwent amyloid PET using [F]-flutemetamol. Tau distribution among the 3 groups was compared using regions of interest-based and voxel-based statistical analyses. RESULTS In svPPA patients, [F]-THK5351 retention was elevated in the anteroinferior and lateral temporal cortices compared with the normal controls group (left>right), and in the left inferior and temporal polar region compared with Alzheimer's disease patients. [F]-THK5351 retention inversely correlated with glucose metabolism, whereas regional THK retention correlated with clinical severity. [F]-flutemetamol scans were negative for β-amyloid. CONCLUSIONS These findings show that [F]-THK5351 retention may be detected in cortical regions correlating with svPPA pathology.

Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors. We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects. We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P

Purpose To investigate whether the position of the central retinal vascular trunk (CRVT), as a surrogate of lamina cribrosa (LC) offset, was associated with the presence of glaucoma in normal-tension glaucoma (NTG) patients. Methods The position of the CRVT was measured as the deviation from the center of the Bruch’s membrane opening (BMO), as delineated by spectral-domain optical coherence tomography imaging. The offset index was calculated as the distance of the CRVT from the BMO center relative to that of the BMO margin. The angular deviation of CRVT was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The offset index and angular deviation were compared between glaucoma and fellow control eyes within individuals. Results NTG eyes had higher baseline intraocular pressure (P = 0.001), a larger β-zone parapapillary atrophy area (P = 0.013), and a larger offset index (PPP Conclusions The offset index was larger in the unilateral NTG eyes, which fact is suggestive of the potential role of LC/BMO offset as a loco-regional susceptibility factor.

Background Although accumulative evidence exists that support the applicability of multi-segmental foot models (MFMs) in evaluating foot motion in various pathologic conditions, little is known of the effect of aging on inter-segmental foot motion. The objective of this study was to evaluate differences in inter-segmental motion of the foot between older and younger adult healthy females during gait using a MFM with 15-marker set. Methods One hundred symptom-free females, who had no radiographic evidence of osteoarthritis, were evaluated using MFM with 15-marker set. They were divided into young (n = 50, 20–35 years old) and old (n = 50, 60–69 years old) groups. Coefficients of multiple correlations were evaluated to assess the similarity of kinematic curve. Inter-segmental angles (hindfoot, forefoot, and hallux) were calculated at each gait phase. To evaluate the effect of gait speed on intersegmental foot motion, subgroup analysis was performed according to the similar speed of walking. Results Kinematic curves showed good or excellent similarity in most parameters. Range of motion in the sagittal (p

Aim Acetabular dysplasia is the one of main causes of hip displacement in patients with cerebral palsy (CP). Although several studies have shown a relationship between hip displacement and acetabular dysplasia, relatively few have evaluated the association between quantitative acetabular dysplasia and related factors, such as Gross Motor Function Classification System (GMFCS) level. Method We performed a morphometric analysis of the acetabulum in patients with CP using multiplanar reformation of computed tomography data. The three directional acetabular indices (anterosuperior, superolateral, and posterosuperior) were used to evaluate acetabular dysplasia. Consequently, linear mixed-effects models were used to adjust for related factors such as age, sex, GMFCS level, and migration percentage. Results A total of 176 patients (mean age 9y 5mo, range 2y 4mo–19y 6mo; 104 males, 72 females) with CP and 55 typically developing individuals (mean age 13y 6mo, range 2y 5mo–19y 10mo; 37 males, 18 females) in a comparison group were enrolled in this study. Statistical modelling showed that all three directional acetabular indices independently increased with GMFCS level (p

Purpose To describe a funduscopic sign that can be used to differentiate between optic disc drusen (ODD) and optic disc oedema (ODE). Methods A total of 73 eyes from 73 consecutive subjects with disc margin blurring who had been evaluated using spectral-domain optical coherence tomography (SD-OCT) were included. Final diagnosis was made by SD-OCT; ODD was defined by direct visualization of ODD, while ODE was defined by documentation of retinal nerve fibre layer oedema (nasal retinal nerve fibre layer thickness >78.0 μm). Peripapillary retina was selected as a two-disc-diameter-sized square image from the fundus photograph. Using MATLAB software, colour photographs were converted to indexed image of eight colours. Presence of a smooth contour strip between the nasal disc margin and juxtapapillary retina was defined as a halo. Whether the halo could predict the ODD was analysed retrospectively. Results The halo sign was detected in 45 eyes (100%) with ODD including one eye with both ODD and ODE. No eyes with ODE alone showed the halo sign. The halo sign implied the presence of ODD (Cohen's kappa = 1.000, p

Background Myopic tilted disc, observed as an oval disc, has been alleged to be a funduscopic en-face manifestation of excessive optic nerve head (ONH) sloping or tilting. Here, we report the case of a myopic child showing a developing oval disc in fundus photos during axial elongation, but without progressive tilting in spectral-domain optical coherence tomography (SD-OCT) images. Case presentation By merging B-scan SD-OCT images of the ONH and macula, the curvature of the posterior pole, including both the fovea and ONH, was reconstructed and compared before and after 2 years of axial elongation. Despite the marked increase of disc ovality, the posterior polar curvature was rarely changed. The preponderance of optic disc change was induced by the shift of the temporal disc margin in the nasal direction. This shifting alone imitated an increase of tilt angle but one that was still far smaller than the required degree of tilt for ONH-tilt-based disc ovality. To clarify, we calculated the required extent of axial elongation to obtain a substantial degree of ONH tilt when considering the adjacency of the fovea and the ONH. Without a focal increase of posterior polar curvature, which is to say posterior staphyloma, such change is not possible until the axial length increases extraordinarily. Conclusion The most prominent change in the development of myopic tilted disc, which change gives it an oval appearance and imitates a tilt when measured, is actually not a tilt but rather a shift of the temporal disc margin.

Background: Insufficient or excessive bony constraint surrounding the talus might contribute to the occurrence of ligamentous injury or bone contusion, respectively, at the time of ankle inversion injuries. This study aimed to investigate the relationship between radiographic lateral ankle instability and osteochondral lesions of the talus (OLT) following ankle inversion injuries. Methods: A total of 195 patients (113 men and 83 women; mean age, 38.7 years) with a history of ankle inversion injuries were included in this study. All patients underwent ankle magnetic resonance imaging (MRI) and stress radiography. The tibiotalar tilt angle on varus stress radiograph, anterior translation of the talus on anterior-drawer lateral radiographs, bimalleolar tilt angle, and fibular position were radiographically determined. The radiographic lateral ankle instability was defined as tibiotalar tilt angle ≥10 degrees, and the presence of OLT was confirmed on MR images. The relationship between the radiographic lateral ankle instability and the presence of OLT was statistically analyzed. Results: The presence of radiographic lateral ankle instability (tibiotalar tilt angle ≥10 degrees) showed an inverse relationship with that of OLT in the chi-squared test ( P = .003). An increased tibiotalar tilt angle was associated with lower incidence of OLT ( P = .011) in the multiple regression analysis, and the presence of OLT was associated with a decreased tibiotalar tilt angle ( P = .016) in the binary logistic regression analysis. Conclusions: This study showed an inverse relationship between lateral ankle instability and the development of OLT following ankle inversion injury. The role of bony constraint in the development of sports injuries in the ankle should be considered with these injuries. Level of Evidence: Level III, diagnostic, comparative study.

Purpose To investigate the baseline position of the central vascular trunk (CVT) and the characteristics of the optic nerve head (ONH) in newborns. Methods CVT position was evaluated based on fundus images obtained from newborns who had undergone eye-screening examinations. It was then graded according to the optic disc area as follows: grade 1, within central 4%; grade 2, within central 9%; grade 3, within central 16%; grade 4, within central 25%; grade 5, outside central 25% of optic disc area. The direction of the CVT position was determined in cases of grade 2 or more as superior, inferior, nasal, and temporal, relative to the optic disc center. The ovality index and the vertical cup-to-disc ratio were determined as well. Results In 1000 fundus images from 1000 newborns, 87.1% showed grade 1 (95% confidence interval 84.7-88.8), and 10.7% showed grade 2. The most common CVT direction was central (87.1%, grade 1), followed by nasal (11.0%) and inferior (1.2%). The ovality index was 1.28 ± 0.09 (range, 1.01-1.61). The ONH shape was vertically oval and highly uniform. The average vertical cup-to-disc ratio was 0.29 ± 0.13 (range, 0.00-0.67). Conclusions The CVT of newborns was located in the central area of the ONH in most cases. The shape of the optic disc was vertically oval, and very similar among the newborns. Considering the high variability of ONH morphology and the diverse location of the CVT in adults, our result suggests that the shape of the ONH and the CVT position might change during eyeball growth.

Recent studies reported that parapapillary microvascular dropout (MvD) was significantly associated with glaucoma and glaucoma progression. To understand the clinical relevance/importance of MvD, it is essential to know the exact vascular anatomy of optic nerve head (ONH). Although it is known that parapapillary choroid and the deep ONH structure including prelaminar tissue are both supplied by branches of short posterior ciliary artery, it remains controversial whether parapapillary choroid provides a major contribution to the prelaminar tissue perfusion. This study investigated perfusion within and around the ONH using indocyanine green angiography. Thirty-three eyes from 33 patients with primary open-angle glaucoma and 10 eyes from 10 normal subjects were included. The temporal sequence of dye appearance in various tissues was analyzed. We also sought the microvessels directly responsible for blood supply to the prelaminar tissue. The perfusion of the prelaminar tissue, which occurred in a sectoral fashion, was dependent on the dye appearance in the adjacent parapapillary choroid. In addition, microvessels crossing over the optic disc margin from the parapapillary choroid to the ONH were found. The findings suggest that the centripetal flow from the parapapillary choroid is an important source of prelaminar tissue perfusion.

Background:This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus.Methods:Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15 degrees were included. All patients underwent a pedobarographic examination along with weightbearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the 2 groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability.Results:The HVA ( P < .001), intermetatarsal angle ( P = .001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instability of the first tarsometatarsal joint ( P = .924). The HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability ( P = .001).Conclusion:The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus. Patients with a greater HVA should be assessed for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.Level of Evidence:Level III, comparative study.

Posterior tibial tendon integrity is an important consideration when treating adult-acquired flatfoot caused by posterior tibial tendon dysfunction. The condition of this tendon traditionally has been evaluated with ultrasonography or magnetic resonance imaging, but recent advances in radiography have increased the resolution of radiographic soft tissue images. The authors examined whether the posterior tibial tendon could be screened with anteroposterior foot radiographs, based on interobserver agreement and accuracy. The authors retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by 2 orthopedic surgeons with foot radiographs and scored as normal or abnormal. The authors evaluated interobserver agreement and compared the findings of ultrasonography and radiography to evaluate diagnostic accuracy. The study included 21 patients with a mean age of 51.5±15.7 years. Ultrasonography showed that 4 patients had normal tendon integrity, 6 patients had tenosynovitis and no tendinopathy, 8 patients had tendinopathy and tendon continuity, and 3 patients had loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of patients (17 of 21). On the basis of the ultrasonographic findings, the surgeons' accuracy was 76.2% (16 of 21) and 61.9% (13 of 21). The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow orthopedic surgeons to predict the prognosis of patients with posterior tibial tendon dysfunction, determine the extent of surgical treatment, and evaluate tendon integrity postoperatively. [ Orthopedics . 2020;43(6):e503–e507.]

The kinematics of the human foot complex have been investigated to understand the weight bearing mechanism of the foot. This study aims to investigate midtarsal joint locking during walking by noninvasively measuring the movements of foot bones using a high-speed bi-planar fluoroscopic system. Eighteen healthy subjects volunteered for the study; the subjects underwent computed tomography imaging and bi-planar radiographs of the foot in order to measure the three-dimensional (3D) midtarsal joint kinematics using a 2D-to-3D registration method and anatomical coordinate system in each bone. The relative movements on bone surfaces were also calculated in the talonavicular and calcaneocuboid joints and quantified as surface relative velocity vectors on articular surfaces to understand the kinematic interactions in the midtarsal joint. The midtarsal joint performed a coupled motion in the early stance to pronate the foot to extreme pose in the range of motion during walking and maintained this pose during the mid-stance. In the terminal stance, the talonavicular joint performed plantar-flexion, inversion, and internal rotation while the calcaneocuboid joint performed mainly inversion. The midtarsal joint moved towards an extreme supinated pose, rather than a minimum motion in the terminal stance. The study provides a new perspective to understand the kinematics and kinetics of the movement of foot bones and so-called midtarsal joint locking, during walking. The midtarsal joint continuously moved towards extreme poses together with the activation of muscle forces, which would support the foot for more effective force transfer during push-off in the terminal stance.

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.

PURPOSE The purpose of this study was to characterize the microstructure of the deep optic nerve tissues in eyes with superior segmental optic nerve hypoplasia (SSOH) in comparison with that in primary open-angle glaucoma (POAG). METHODS Thirty-five eyes with SSOH, 37 eyes with POAG, and 54 healthy control eyes underwent enhanced depth imaging (EDI) volume scanning of the optic nerve using spectral-domain optical coherence tomography (SD-OCT). POAG patients were matched with SSOH patients in terms of the thickness of the neuroretinal rim and the retinal nerve fiber layer in the superior sector. The lamina cribrosa thickness (LCT) was determined in 3 equidistant planes, and anterior lamina cribrosa surface depth (LCD) was determined in 5 equidistant planes. The measurements were compared between groups, and the areas under the receiver operating characteristic curves (AUC) were obtained for each parameter. RESULTS Eyes with SSOH had larger LCT and smaller LCD than POAG eyes at all locations (all P