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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.

Breech presentation is one of the most important risk factors for developmental dysplasia of the hip, and all breech infants should be screened. The necessity of further follow-up of developmental dysplasia of the hip after normal clinical and sonographic screening is a controversial subject. The purpose of this study to identify the incidence of delayed dysplasia in breech infants after normal ultrasound screening and the necessity of further clinical and radiologic follow-up in these patients.We included the 292 breech babies (128 boys and 164 girls) who showed normal hip ultrasound screening results. To determine the incidence of delayed radiographic dysplasia, anteroposterior hip radiographs were taken between 12 and 24 months of age to measure the acetabular index (AI).The mean AI values were 22.8±3.4 in boys and 24.9±3.1 in girls. Applying the Tönnis criteria, 29 patients (9.9%) were considered to have delayed radiographic dysplasia (16 boys and 13 girls). No significant difference was found in any demographic variables between babies with and without delayed radiographic dysplasia. None of these 29 infants underwent any treatment for radiographic dysplasia. Applying Kuong's criteria to 292 infants, only 2 patients (0.7%) demonstrated radiographic dysplasia on the hip anteroposterior radiographs taken at 14 months.The incidence of radiographic dysplasia significantly varied depending on which criteria were applied. In order to find out more accurate incidence rates of delayed radiographic dysplasia, large-scale studies of the normative AI data for Korean infants are required.Prognostic Level III.

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.

Supplemental Digital Content is available in the text., Background: Computed tomography (CT) provides benefits for 3-dimensional (3D) visualization of femur deformities. However, the potential adverse effects of radiation exposure have become a concern. Consequently, a biplanar imaging system EOS has been proposed to enable reconstruction of the 3D model of the femur. However, this system requires a calibrated apparatus, the cost of which is high, and the area occupied by it is substantial. The purpose of this study was to develop a mobile application that included a new method of 3D reconstruction of the femur from conventional radiographic images and to evaluate the validity and reliability of mobile the application when measuring femoral anteversion. Methods: The statistical shape model, graph-cut algorithm, and iterative Perspective-n-Point algorithm were utilized to develop the application. The anteroposterior and lateral images of a femur can be input using the embedded camera or by file transfer, and the touch interface aids accurate contouring of the femur. Regarding validation, the CT scans and conventional radiographic images of 36 patients with cerebral palsy were used. To evaluate concurrent validity, the femoral anteversion measurements on the images reconstructed from the mobile application were compared with those from the 3D CT images. Three clinicians assessed interobserver reliability. Results: The mobile application, which reconstructs the 3D image from conventional radiographs, was successfully developed. Regarding concurrent validity, the correlation coefficient between femoral anteversion measured using 3D CT and the mobile application was 0.968 (P

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.

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 investigate the usefulness of bone single-positron emission tomography/computed tomography (SPECT/CT) of the hip in predicting the later occurrence of avascular necrosis (AVN) after slipped capital femoral epiphysis (SCFE) or femoral neck fracture in pediatric patients. The quantitative parameters of SPECT/CT useful in predicting AVN were identified.Twenty-one (male:female, 10:11) consecutive patients aged18 years (mean age ± standard deviation [SD], 11.0 ± 2.7 years) who underwent surgery for SCFE or femoral neck fracture and postoperative bone SPECT/CT were included. The maximum standardized uptake value (SUV), mean SUV, and minimum SUV of the femoral head were measured. The ratios of the maximum SUV, mean SUV, and minimum SUV of the affected femoral head to the contralateral side were determined. Patients were followed up for1 year after the surgery. The SPECT/CT parameters were compared between patients who developed AVN and those who did not. The accuracy of SPECT/CT parameters for predicting AVN was assessed.Six patients developed AVN. There was a significant difference in the ratio of the mean SUV among patients who developed AVN (mean ± SD, 0.8 ± 0.3) and those who did not (1.1 ± 0.2,Quantitative bone SPECT/CT is useful for evaluating femoral head viability in pediatric patients with SCFE or femoral neck fractures. Clinicians should consider the high possibility of later AVN development in patients with a decreased mean SUV ratio.

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.

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

Background 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.

Background and purpose — There are few studies on overgrowth of the affected limb after treatment of developmental dysplasia of the hip (DDH). We investigated the incidence of overgrowth and its risk factors in DDH patients. Patients and methods — 101 patients were included in this study. Overgrowth was defined by 2 criteria: when the height of the femoral head of the affected side was higher than that of the contralateral side by more than 10 mm, or by more than 15 mm. The potential risk factors of distinct overgrowth were retrospectively examined using multivariable analysis. Results — When overgrowth was defined as femoral head height difference (FHHD) > 10 mm, its incidence was 44%, and only femoral osteotomy was identified as a significant risk factor with a relative risk (RR) of 1.6 (95% confidence interval [CI] 1.0–2.5). When overgrowth was defined as FHHD > 15 mm, its incidence was 23%, and femoral osteotomy was identified as the only significant risk factor with an RR of 2.3 (CI 1.2–4.5). Overgrowth developed more frequently in patients who underwent femoral osteotomy at the age of 2 to 4 years (87%) than in the others (46%) (p = 0.04). Interpretation — Overgrowth of the affected limb is common in DDH patients. Patients who underwent femoral osteotomy, especially at the age of 2 to 4 years, may require careful follow-up because of the substantial risk for overgrowth.

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.

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

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

Background: 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 examine the efficacy, safety, and clinical outcomes of distraction osteogenesis through the physis (PDO) or through subphyseal osteotomy (SPDO) in patients with atrophic-type congenital pseudarthrosis of tibia with proximal tibial dysplasia. Methods To validate the efficacy and safety of PDO and SPDO, radiographic and clinical parameters were compared between 5 patients who underwent proximal tibial metaphyseal or metadiaphyseal lengthening as a control (group 1) and 7 patients who underwent PDO or SPDO (group 2). Postoperative complication was also compared between the groups. Results A significant difference in terms of healing index (group 1, 83.3±24.7 d/cm; group 2, 35.0±11.1 d/cm; P=0.001) and percentage increase (11.0%±3.7% vs. 23.1%±10.5%, P=0.034) was observed between the 2 groups. According to the Paley classification, group 1 included 1 "problems" case and 3 "obstacles" cases, whereas group 2 included 2 "problems" cases and 1 "obstacles" case. According to the Lascombes classification, group 1 included 2 grade IIIb cases and 3 grade IV cases, whereas group 2 included 6 grade I cases and 1 grade IIa case. Severe complications were significantly higher in group 1 compared with the group 2 (P=0.007). Conclusions This study demonstrated that PDO or SPDO can be effectively and safely performed for tibial lengthening in atrophic-type congenital pseudarthrosis of tibia patients with proximal tibial dysplasia. Level of evidence Level III.

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.]

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.

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

The purpose of this study was to evaluate the clinical utility of targeted exome sequencing (TES) as a molecular diagnostic tool for patients with skeletal dysplasia. A total of 185 patients either diagnosed with or suspected to have skeletal dysplasia were recruited over a period of 3 years. TES was performed for 255 genes associated with the pathogenesis of skeletal dysplasia, and candidate variants were selected using a bioinformatics analysis. All candidate variants were confirmed by Sanger sequencing, correlation with the phenotype, and a cosegregation study in the family. TES detected “confirmed” or “highly likely” pathogenic sequence variants in 74% (71 of 96) of cases in the assured clinical diagnosis category and 20.3% (13 of 64 cases) of cases in the uncertain clinical diagnosis category. TES successfully detected pathogenic variants in all 25 cases of previously known genotypes. The data also suggested a copy-number variation that led to a molecular diagnosis. This study demonstrates the feasibility of TES for the molecular diagnosis of skeletal dysplasia. However, further confirmation is needed for a final molecular diagnosis, including Sanger sequencing of candidate variants with suspected, poorly captured exons. Genet Med 18 6, 563–569.

Isotretinoin, a vitamin A derivative, is known to induce premature epiphyseal closure. We report the case of a 9-year-old boy with neuroblastoma who demonstrated premature epiphyseal closure after 1 year of isotretinoin treatment (72.3 mg/m2/day). A bone bridge developed on the bilateral proximal tibial growth plate resulting in genu varum. We performed hemiepiphysiodesis on the bilateral proximal tibia in anticipation of the spontaneous resolution of the bone bridge. Genu varum on the left side was corrected with the resolution of bone bridge. For the remaining bone bridge on the right side, arthroscopy-assisted physeal bar resection was performed, and genu varum on the right lower extremity was also corrected. A regular review of the alignment of the upper and lower limbs is necessary to provide timely intervention in patients using isotretinoin, considering the possibility of premature epiphyseal closure.

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.

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

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

SummaryObjectiveWe sought to determine (1) whether change in the tibial plateau inclination (TPI) after high tibial osteotomy (HTO) is different from change in the knee joint line orientation (KJLO) relative to the ground; (2) whether, in varus knee OA patients before and after HTO, these radiographic measures are different from those in normal control; and (3) whether the postoperative values of the TPI and KJLO relative to the ground are associated with short term clinical outcome scores after HTO.DesignFifty patients who underwent HTO and 75 normal controls were assessed with four radiographic measures. We compared the measures before HTO with those after HTO and with those of the normal controls, then examined associations between the postoperative radiographic measures and clinical outcome scores 1-year after HTO.ResultsAfter HTO, TPI increased 9.0°, whereas KJLO relative to the ground only increased 4.1°, with a compensatory change of the ankle joint line orientation. However, the postoperative KJLO relative to the ground in the HTO group was significantly different from that of the normal controls (mean difference, 4.9°; P

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.

This study evaluated the correlation between central and peripheral bone mineral density (BMD) of the ankle joint, using dual-energy X-ray absorptiometry (DXA). We also investigated whether peripheral ankle BMD could be used to identify individuals who were diagnosed with osteoporosis, using central DXA. We recruited 134 volunteers aged 20–90 years who agreed to participate in this study. Central BMD of the lumbar spine and left femur, and peripheral BMD of the medial malleolus, distal tibia, lateral malleolus, and talus were measured with DXA. Among the peripheral sites of the ankle, the highest and lowest BMD were observed in the talus and lateral malleolus, respectively. All peripheral DXA measurements of the ankle joint were significantly correlated with central DXA measurements. There was a good correlation (r: 0.656–0.725) between peripheral and central BMD for the older age group (> 50 years), but fair-to-good correlation (r: 0.263–0.654) for the younger age group (

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

We aimed to investigate the clinical characteristics of slipped capital femoral epiphysis (SCFE) in patients aged less than 10 years and identify the efficacy of physeal-sparing procedures in this age group. Demographic data of 18 SCFE patients aged less than 10 years were compared with those of 71 older patients to investigate the clinical characteristics. The efficacy of physeal-sparing procedures (n=5) was investigated compared with that of in-situ screw fixation (n=13). Obese children were noticeably more common among SCFE patients aged less than 10 years (P=0.034). The slip angle improved significantly more in the physeal-sparing subgroups (P=0.038) without the occurrence of further slippage. Moreover, physeal-sparing procedures allow persistent growth of the proximal femoral physis. However, most of the patients in the physeal-sparing subgroup needed additional surgeries when the proximal femoral physis outgrew the implant. Obesity may be associated more with early-onset SCFE (onset

Purpose We aimed to investigate the prevalence of diabetic retinopathy (DR) in patients with diabetic foot ulcer (DFU) and elucidate the association between DR and DFU severities and their shared risk factors. Methods A retrospective review was conducted on DFU patients who underwent ophthalmic and vascular examinations within 6 months; 100 type 2 diabetic patients with DFU were included. The medical records of 2496 type 2 diabetic patients without DFU served as control data. DR prevalence and severity were assessed in DFU patients. DFU patients were compared with the control group regarding each clinical variable. Additionally, DFU patients were divided into two groups according to DR severity and compared. Results Out of 100 DFU patients, 90 patients (90%) had DR and 55 (55%) had proliferative DR (PDR). There was no significant association between DR and DFU severities (R = 0.034, p = 0.734). A multivariable analysis comparing type 2 diabetic patients with and without DFUs showed that the presence of DR [OR, 226.12; 95% confidence interval (CI), 58.07–880.49; p < 0.001] and proliferative DR [OR, 306.27; 95% CI, 64.35–1457.80; p < 0.001), higher HbA1c (%, OR, 1.97, 95% CI, 1.46–2.67; p < 0.001), higher serum creatinine (mg/dL, OR, 1.62, 95% CI, 1.06–2.50; p = 0.027), older age (years, OR, 1.12; 95% CI, 1.06–1.17; p < 0.001), higher pulse pressure (mmHg, OR, 1.03; 95% CI, 1.00–1.06; p = 0.025), lower cholesterol (mg/dL, OR, 0.94; 95% CI, 0.92–0.97; p < 0.001), lower BMI (kg/m2, OR, 0.87, 95% CI, 0.75–1.00; p = 0.044) and lower hematocrit (%, OR, 0.80, 95% CI, 0.74–0.87; p < 0.001) were associated with DFUs. In a subgroup analysis of DFU patients, the PDR group had a longer duration of diabetes mellitus, higher serum BUN, and higher serum creatinine than the non-PDR group. In the multivariable analysis, only higher serum creatinine was associated with PDR in DFU patients (OR, 1.37; 95% CI, 1.05–1.78; p = 0.021). Conclusions Diabetic retinopathy is prevalent in patients with DFU and about half of DFU patients had PDR. No significant association was found in terms of the severity of these two diabetic complications. To prevent blindness, patients with DFU, and especially those with high serum creatinine, should undergo retinal examinations for timely PDR diagnosis and management.

Purpose The aim of this study was to establish normative values and to identify age-related change in physical examinations that are commonly used while evaluating patients with cerebral palsy (CP). Materials and methods One hundred four healthy volunteers (mean age 36 years, standard deviation 15 years) were enrolled and divided into four age groups: 13-20, 21-35, 36-50, and 51 years and older. The eighteen physical examination tests for CP were selected by five orthopedic surgeons in consensus-building session. The measurements were taken by three orthopedic surgeons. Results There was no significant difference in the measures of physical examination among all the age groups, except for the Staheli test (p=0.002). The post hoc test revealed that the mean hip extension was 2.7° higher in the 13-20-year-old group than in the other age groups. The bilateral popliteal angle had a tendency to increase in those over 36-years-old. There were 31 participants (30%) with a unilateral popliteal angle greater than 40°. Conclusion We documented normative values that can be widely used for evaluating CP in patients 13 years and older.

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.