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

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.

Patients’ perspectives on the conventional synthetic cast vs a newly developed open cast for ankle sprains

BACKGROUND Idiopathic pes planovalgus is one of the most common foot deformities in children and adolescents. However, there is a discrepancy between subjective symptoms and radiographic severity in idiopathic planovalgus deformity, and very few studies have investigated this aspect. Further, the assessment of subjective symptoms in patients with pes planovalgus requires a quantitative scoring system for making meaningful comparisons, such as the Oxford Ankle Foot Questionnaire for Children (OxAFQ-c) and that for parents (OxAFQ-p). Therefore, the purpose of this study was to evaluate the factors affecting the symptoms of idiopathic planovalgus using the OxAFQ. METHODS All patients who were ≤18 years of age, had visited our clinic for the evaluation of pes planovalgus deformity, and had completed the OxAFQ were included in this study. The anteroposterior talo-first metatarsal, lateral talo-first metatarsal, and hallux valgus angles were measured on weight-bearing radiographs. The data were analyzed using a multiple regression model, with age, sex, and radiographic indices as explanatory variables. RESULTS Overall, 123 patients were enrolled in this study, and 246 standing foot radiographs were evaluated along with scores in each domain of the OxAFQ. The factors affecting physical domain scores in the OxAFQ-c were female sex (p = 0.047) and the anteroposterior talo-first metatarsal angle (p = 0.033). Age of ≥10 years was a significant factor (p < 0.05) affecting all domains in both the OxAFQ-c and OxAFQ-p other than the physical domain score. CONCLUSIONS Although pes planovalgus deformity is 3-dimensional, the forefoot abduction component of the deformity should be carefully assessed as it is closely related to subjective symptoms. Further, in female patients with a more severe anteroposterior talo-first metatarsal angle, an aggravation of symptoms with aging should be expected when managing pes planovalgus deformity. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Some patients with cerebral palsy (CP) exhibit excessive knee flexion at initial contact followed by knee hyperextension (KE) in mid-stance. Research question This study investigated the change in sagittal kinematics after distal hamstring lengthening (DHL) and triceps surae lengthening procedures in CP patients with KE, and compared it to those without KE. In addition, the risk factors for the worsening of postoperative KE were analyzed. Methods Consecutive 312 patients (596 limbs) with CP who underwent DHL and triceps surae lengthening were included. All patients underwent preoperative and 1-year postoperative three-dimensional gait analysis. Patients’ limbs were divided into the KE and knee flexion (KF) groups, according to preoperative minimum knee flexion in stance. KE was defined as minimum knee flexion in stance less than 0°. Results The KE and KF groups included 130 and 466 limbs, respectively. Knee and ankle sagittal kinematics significantly improved after surgery in both groups. Minimum knee flexion in stance significantly increased from -6.6˚ to 0.5˚ in the KE group, but decreased from 14.6˚ to 7.8˚ in the KF group. Among the KE group, minimum knee flexion in stance improved in 103 limbs (79.2 %), but worsened in 27 limbs (20.8 %). Degree of preoperative KE was the only factor significantly associated with postoperative worsening of KE (p=0.002). The cutoff value for the worsening of KE was -5.8˚ of preoperative minimum knee flexion in stance. Significance This study demonstrated that the sagittal kinematics of the knee and ankle joints improved after DHL and triceps surae lengthening procedures in CP patients with and without KE. Preoperative degree of KE was a risk factor for the worsening of KE after surgery. Therefore, careful selection for indication of DHL is required to prevent postoperative KE due to overlengthening of the hamstrings, particularly in patients with severe preoperative KE.

Background This study evaluate the radiographic changes in the mid-tarsal joint, including the calcaneocuboid and talonavicular (TN) joints after calcaneal lengthening for planovalgus deformity in children. Methods This study included 38 patients (68 feet) who underwent calcaneal lengthening for planovalgus deformity. Radiographic osteoarthritic changes at the CC or TN joint were defined as modified Kellgren–Lawrence grade of ≥1. Results Among the 68 feet, 31 feet (45.6%) showed radiographic osteoarthritic changes at the CC joint and 20 (29.4%) showed changes at the TN joint. Risk of radiographic osteoarthritic changes at the CC joint was associated with increased age at surgery (OR = 1.2, p = 0.038). Risk of radiographic osteoarthritic changes at the TN joint was associated with increased age at surgery (OR = 2.2; p = 0.002), preoperative AP talus-1st metatarsal angle (OR = 1.1; p = 0.044), and degree of CC subluxation (OR = 2.1; p = 0.007). Conclusions Surgeons should consider the risk factors in the surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.

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 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.

Background:This study aimed to investigate the radiographic measurements associated with the progression of hallux valgus during at least 2 years of follow-up.Methods:Seventy adult patients with hallux valgus who were followed for at least 2 years and underwent weightbearing foot radiography were included. Radiographic measurements included the hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle (IMA), metatarsus adductus angle, distal metatarsal articular angle (DMAA), tibial sesamoid position, anteroposterior (AP) talo–first metatarsal angle, and lateral talo–first metatarsal angle. Patients were divided into progressive and nonprogressive groups. Binary logistic regression analysis was performed to identify factors that significantly affected the progression of hallux valgus deformity. The correlation between change in HVA and changes in other radiographic indices during follow-up was analyzed.Results:The DMAA ( P = .027) and AP talo–first metatarsal angle ( P = .034) at initial presentation were found to be significant factors affecting the progression of hallux valgus deformity. Change in the HVA during follow-up was significantly correlated with changes in the IMA ( r = 0.423; P = .001) and DMAA ( r = 0.541; P < .001).Conclusion:The change in the HVA was found to be significantly correlated with changes in the IMA and DMAA. A future study is required to elucidate whether this correlation can be explained by the progressive instability of the first tarsometatarsal joint. We believe special attention needs to be paid to patients with pes planus and increased DMAA.Level of Evidence:Level III, comparative study.

This retrospective study was conducted to investigate the correlation between kinetic gait parameters and femoral bone mineral density (BMD) in elderly subjects aged 50 years and older that could walk independently. Four hundred and twenty-six subjects (158 men and 258 women; mean age 68.7 years, standard deviation (SD) 7.9 years) were included in the study. BMDs (g/cm2) of the femoral neck, trochanter, shaft, and total proximal femur were collected. Kinetic data including maximum hip power and hip power-time integral was obtained from a three-dimensional gait analysis with self-selected walking speed. Correlation between BMDs of proximal femur and gait kinetic data was analyzed. Multiple regression analysis was also performed to identify factors significantly associated with BMD. Correlation between BMD and hip kinetic data was not prominent in elderly men. In women, BMD was significantly correlated with hip kinetic data. Hip power-time integral showed greater correlation with BMD than maximum hip power during gait in elderly women. Age (p

Background:Ankle stress radiographs are important tools for evaluating chronic lateral ankle instability. The consistency of a patient’s ankle condition as it affects the reliability of ankle stress radiographs has never been evaluated.Purpose:To investigate the consistency and reliability of ankle stress radiographs in patients with chronic lateral ankle instability without an ankle injury during the study period.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Included were patients with chronic lateral ankle instability who underwent 2 repeated ankle stress radiographs between January 2014 and July 2019; those with an ankle injury during the study period were excluded. The tibiotalar tilt angle on varus stress radiographs and anterior translation of the talus on anterior drawer stress radiographs were measured at initial presentation and final follow-up examination. Interobserver reliability and consistency of ankle stress radiographs were analyzed using the intraclass correlation coefficient (ICC).Results:A total of 45 patients (mean ± standard deviation age, 36.4 ± 13.4 years; 18 men and 27 women; follow-up duration, 9.1 ± 3.2 months) were included. The mean ± standard deviation tibiotalar tilt angle and anterior talar translation at initial presentation were 10.8° ± 5.2° and 6.9 ± 2.7 mm, respectively. The interobserver reliabilities of the tibiotalar tilt angle and anterior talar translation were excellent (ICC = 0.926 [95% CI, 0.874-0.959] and 0.911 [95% CI, 0.766-0.961], respectively). The consistency between the initial and final radiographs was good for tibiotalar tilt angle (ICC = 0.763 [95% CI, 0.607-0.862]) and poor for anterior talar translation (ICC = 0.456 [95% CI, 0.187-0.660]).Conclusion:Although the interobserver reliability of the radiographic measurements was excellent, the consistency of the ankle stress radiographs was not as acceptable. Surgeons need to be cautious when deciding whether to operate on a patient with chronic lateral ankle instability based on a single ankle stress radiograph.

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.

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.]

This study was to analyze intrasubject radiographic progression of the hallux valgus deformity by comparing the mildly and severely affected sides in patients with bilateral asymmetric hallux valgus in the whole group as well as the metatarsus adductus and the nonmetatarsus adductus subgroups. A total of 186 patients with bilateral asymmetrical hallux valgus deformity with a difference of 5° or greater in the hallux valgus angle were included, and 11 radiographic measurements were analyzed. The radiographic differences between the mildly and severely affected sides were compared. Correlation between the changes in the hallux valgus angle and those in other measurements was analyzed, and multiple regression analyses were performed. The anteroposterior talo-second metatarsal angle showed no significant difference between the mildly and severely affected sides. Changes in the intermetatarsal angle and sesamoid rotation angle were significantly associated with the progression of hallux valgus angle in the whole group as well as the nonmetatarsus adductus subgroup. Change in the intermetatarsal angle (p = .006) was the significant factor associated with the progression of hallux valgus angle in the metatarsus adductus subgroup. The anteroposterior talo-second metatarsal angle might be useful in evaluating the overall foot shape in the hallux valgus deformity. Progression of the hallux valgus deformity might be pathophysiologically different between those with and without metatarsus adductus.

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

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

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

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

Background: Radiographic examination is a widely used evaluation method in the orthopedic clinic. However, conventional radiography alone does not reflect the dynamic changes between foot and ankle segments during gait. Multiple 3-dimensional multisegment foot models (3D MFMs) have been introduced to evaluate intersegmental motion of the foot. In this study, we evaluated the correlation between static radiographic indices and intersegmental foot motion indices. Methods: One hundred twenty-five females were tested. Static radiographs of full-leg and anteroposterior (AP) and lateral foot views were performed. For hindfoot evaluation, we measured the AP tibiotalar angle (TiTA), talar tilt (TT), calcaneal pitch, lateral tibiocalcaneal angle, and lateral talcocalcaneal angle. For the midfoot segment, naviculocuboid overlap and talonavicular coverage angle were calculated. AP and lateral talo-first metatarsal angles and metatarsal stacking angle (MSA) were measured to assess the forefoot. Hallux valgus angle (HVA) and hallux interphalangeal angle were measured. In gait analysis by 3D MFM, intersegmental angle (ISA) measurements of each segment (hallux, forefoot, hindfoot, arch) were recorded. Results: ISAs at midstance phase were most highly correlated with radiography. Significant correlations were observed between ISA measurements using MFM and static radiographic measurements in the same segment. In the hindfoot, coronal plane ISA was correlated with AP TiTA ( P < .001) and TT ( P = .018). In the hallux, HVA was strongly correlated with transverse ISA of the hallux ( P < .001). Conclusion: The segmental foot motion indices at midstance phase during gait measured by 3D MFM gait analysis were correlated with the conventional radiographic indices. Clinical Relevance: The observed correlation between MFM measurements at midstance phase during gait and static radiographic measurements supports the fundamental basis for the use of MFM in analysis of dynamic motion of foot segment during gait.

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.

Magnetic resonance imaging (MRI) provides an accurate method of observing and diagnosing injuries of the ligament complex of the ankle. However, the association between ankle symptoms and MRI findings has been unclear. The purpose of the present study was to evaluate the relationship between ankle pain and MRI findings. This prospective study included 40 patients with ankle pain after inversion injury and 10 healthy volunteers. Correlations among the ankle symptoms (tenderness on the anterior talofibular ligament, pain during varus stress in a neutral and plantarflexed ankle), and MRI findings were analyzed. A complete tear of the anterior talofibular ligament correlated with ankle pain during varus stress in the neutral position (r = 0.365, p = .031) and tenderness at the anterior talofibular ligament (r = 0.362, p = .032). The results of our study suggest that a complete tear of the anterior talofibular ligament will correlate with lateral ankle pain.

Purpose To investigate the effect of partial biceps lengthening on elbow flexion posture and active elbow flexion and extension in patients with cerebral palsy. Methods We retrospectively reviewed 29 patients with cerebral palsy who underwent anterior elbow release as part of multilevel upper extremity surgery. The early series of the patients (N = 14; group 1) had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous adventitia off the biceps tendon. The later series of patients (N = 15; group 2) had partial biceps tendon lengthening in addition to the procedures in group 1. We compared the 2 sets of patients for elbow flexion posture, active elbow flexion and extension, forearm rotation, and House scores, with mean follow-ups of 72 months for group 1 and 31 months for group 2. Results The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House scores. Group 2 patients had more improvement in flexion posture (53° vs 44°) and active extension (23° vs 15°) than group 1 postoperatively. However, group 2 had a mean decrease of 7° in active elbow flexion, whereas group 1 had no changes. There was no difference in forearm supination or in the improvement of House scores between groups. Conclusions Early results of partial lengthening of the biceps tendon showed that it may improve elbow flexion posture and active elbow extension in patients with flexion deformity in cerebral palsy. Type of study/level of evidence Therapeutic III.

Although several studies have reported on the outcomes of rectus femoris transfer (RFT), few have investigated the multiple factors that could affect the results. Therefore, we evaluated the outcomes of RFT and analyzed factors that influence improvement and annual change in knee motion after surgery in patients with cerebral palsy (CP).We reviewed ambulatory patients with CP who were followed up after they had undergone RFT as part of a single-event multilevel surgery (SEMLS) and who had undergone preoperative and postoperative three-dimensional (3D) gait analysis between January 1995 and December 2012. Relevant kinematic values, including peak knee flexion, knee range of motion, and timing of peak knee flexion in the swing phase and gait deviation index (GDI) score, were the outcome measures. Improvements in rate of angle and GDI score were adjusted by multiple factors such as sex, Gross Motor Function Classification System (GMFCS) level, anatomic type of CP, and concomitant surgeries as the fixed effects, and follow-up duration, laterality, and each subject as the random effects, all of which was performed using a linear mixed model.A total of 290 patients (487 limbs) and 612 3D gait analysis (2-4 per patient) results were finally included in this study. At 2 years after RFT, estimated mean peak knee flexion (1.2°, p=0.005), estimated mean knee range of motion (10.7°, p0.001), and estimated mean GDI score (7.3, p0.001) increased significantly. Peak knee flexion in the swing phase occurred 5.4% earlier after surgery compared with that at baseline (p0.001). In serial postoperative gait analyses, peak knee flexion in the swing phase occurred 0.8% earlier per year in patients with GMFCS level I or II (p=0.021).RFT as part of a SEMLS was effective in treating stiff knee gait. In serial postoperative gait analyses, patients with GMFCS level I or II showed better prognosis than those with level III with regard to timing of peak knee flexion in the swing phase.Prognostic level IV.

The clinical success of ankle joint arthroplasty depends on the availability of information on the morphology of the relevant bones. Thus, the implant design and surgical technique should be adjusted to the ankle morphology. However, few reports have described the characteristics of ankle morphometry in Korean populations. The present study evaluated the characteristics of ankle morphometry in a Korean population sample. Weightbearing ankle radiographs of 100 Korean patients were retrieved, and 13 representative indexes were measured after establishing the reliability of the measurements. Ankle morphometry was analyzed in terms of (1) size diversity, (2) aspect (anteroposterior/mediolateral) ratio, (3) distal anteroposterior inclination angle, and (4) complication-related anatomy. The measurements were compared with those of previous studies of white populations. In terms of size diversity, the ankle morphometry in Koreans was smaller in all parameters, except for the talar width. Koreans had a different aspect ratio than whites. The increase in the distal anteroposterior inclination angle was statistically significant (p < .001), and complication-related indexes were also significantly increased. In addition to the smaller dimensions in Korean populations, surgeons should be aware of the characteristics of Korean patients, such as the steep slope and vulnerability to iatrogenic malleolar fractures.

Background Kabuki syndrome is a rare genetic disorder characterized by distinct dysmorphic facial features, growth deficiency, intellectual disabilities, unusual dermatoglyphic patterns, and skeletal abnormalities. The incidence of hip dislocation in Kabuki syndrome ranges from 18% to 62%. We reviewed the outcomes of management of hip dislocations in patients with Kabuki syndrome with special attention to the diagnostic processes for hip dislocation and Kabuki syndrome. Methods Among 30 patients with mutation-confirmed Kabuki syndrome, we selected six patients who had hip dislocations and reviewed their medical records and plain radiographs. The modes of presentation and diagnostic processes for both hip dislocations and Kabuki syndrome were investigated. The management and treatment outcomes of hip dislocations in patients with Kabuki syndrome were evaluated. Results The average age of patients at the time of diagnosis of hip dislocation was 7.7 months (range, 1 week to 22 months). None of the patients were diagnosed as having Kabuki syndrome at that time. Two patients were treated with a Pavlik harness; one, with closed reduction; two, with open reduction and later pelvic and/or femoral osteotomies; and one, with open reduction combined with pelvic osteotomy. The patients were followed up for 5.8 years on average (range, 2.0 to 10.5 years). The radiologic outcome was graded as Severin IA or IB for three patients who were older than 6 years at the latest follow-up (mean age, 9.9 years; range, 7.8 to 12.4 years). In the remaining three patients younger than 6 years (mean age, 3.8 years; range, 2.7 to 5.3 years), the lateral center edge angle was more than 15°. The clinical diagnosis of Kabuki syndrome was made during follow-up after hip dislocation treatment and confirmed by mutational analysis at a mean age of 4.7 years. The mean interval between the diagnosis of hip dislocation and Kabuki syndrome was 4.0 years. Conclusions The management of hip dislocation by conservative or surgical method showed successful results. Awareness of Kabuki syndrome could lead to an early diagnosis of this rare disease in patients with hip dislocation and allow for early detection of other underlying conditions and multidisciplinary management.

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

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

Distal hamstring lengthening (DHL) is a commonly performed procedure in flexed knee gait. However, the necessity of this procedure has been challenged due to the concerns on adverse effects in long-term follow-up. This retrospective study was undertaken to investigate the long-term outcome of single event multilevel surgery (SEMLS), including bilateral DHL, in ambulatory patients with cerebral palsy using 3D gait analysis. Twenty-nine ambulatory patients with spastic diplegic cerebral palsy who had undergone SEMLS including bilateral DHL were included. 3D gait analysis was performed preoperatively, 1 year postoperatively and over 10 years postoperatively. Preoperative temporal parameters, kinematics and GDI were compared with values obtained 1 and 10 year follow-up visits. The mean age of patients at time of first surgery was 8.3 years (range, 5.4-16.3 years), and mean time from first surgery to last 3D gait analysis was 11.8 years (range, 10.0-13.3 years). Mean pelvic tilt was not changed significantly after SEMLS including DHL. Mean knee flexion at initial contact decreased from 31.1° preoperatively to 26.0° at 1 year postoperatively (p=0.065), and then decreased significantly to 23.6° at 10 years postoperatively (p=0.038) versus the preoperative value. Mean GDI score significantly improved from 69.4 preoperatively to 77.9 at 1 year postoperatively (p=0.003) and continuously improved to 82.2 at 10 years postoperatively (p=0.017). Single event multilevel surgery including DHL provides a favorable outcome 10 years postoperatively in patients with spastic diplegic cerebral palsy.

This pilot study was performed to evaluate the correlation between central bone mineral density (BMD) and peripheral BMD around the elbow in children and adolescents and to compare BMD values across skeletal sites. Twenty-seven healthy volunteers between 5 and 18 yr of age were recruited for the study. Anthropometric measurements including height and weight were performed. Central BMD at the lumbar spine and left femur and peripheral BMD at the supracondylar area, medial condyle, lateral condyle, and olecranon were measured using dual-energy X-ray absorptiometry (DXA). Higher BMD levels were found in the central skeleton (lumbar spine and femur) than in peripheral sites around the elbow (p

Background: This study was performed to investigate the relationship between coronal computed tomography (CT) and Broden's view in terms of location of the fracture line and fracture pattern. Methods: Forty-five feet of 45 patients with intraarticular calcaneal fractures were evaluated. The mean age of the patients was 46.3 years (standard deviation, 18.1; range, 15 to 80 years), and there were 34 men and 11 women. The Broden's views were ac- quired using the ray sum projection, reviewed, and correlated with the coronal CT image to determine the location of the fracture on the posterior facet and fracture pattern described by the Sanders classification. The quantified location of the fracture line was defined as the distance between the medial margin of posterior facet and the fracture line divided by the whole length of the pos - terior facet, which was expressed as a percentage. Results: The fracture line on the Broden's view was positioned at 22.3% (standard deviation, 29.6) laterally compared to that on coronal CT (p < 0.01). Although all cases showed posterior facet involvement on the CT scan, the fracture line was positioned lat- eral to the posterior facet in 6 cases (13.3%) in the Broden's view. The coronal CT and Broden's view showed a low level of agree- ment in the fracture pattern according to the Sanders classification, with kappa values of 0.23. Conclusions: Surgeons should consider that the fracture line on the Broden's view shows positioning laterally compared to coro- nal CT and they should consider that the fracture line at the lateral to posterior facet on the Broden's view might be an intraarticu- lar fracture line. There are some limitations when applying the Sanders classification with the Broden's view.

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

Background: Intra-class correlation coeffi cients (ICCs) provide a statistical means of testing the reliability. However, their interpretation is not well documented in the orthopedic fi eld. The purpose of this study was to investigate the use of ICCs in the orthopedic literature and to demonstrate pitfalls regarding their use. Methods: First, orthopedic articles that used ICCs were retrieved from the Pubmed database, and journal demography, ICC models and concurrent statistics used were evaluated. Second, reliability test was performed on three common physical examinations in cerebral palsy, namely, the Thomas test, the Staheli test, and popliteal angle measurement. Thirty patients were assessed by three orthopedic surgeons to explore the statistical methods testing reliability. Third, the factors affecting the ICC values were examined by simulating the data sets based on the physical examination data where the ranges, slopes, and interobserver variability were modifi ed. Results: Of the 92 orthopedic articles identifi ed, 58 articles (63%) did not clarify the ICC model used, and only 5 articles (5%) described all models, types, and measures. In reliability testing, although the popliteal angle showed a larger mean absolute difference than the Thomas test and the Staheli test, the ICC of popliteal angle was higher, which was believed to be contrary to the context of measurement. In addition, the ICC values were affected by the model, type, and measures used. In simulated data sets, the ICC showed higher values when the range of data sets were larger, the slopes of the data sets were parallel, and the interobserver variability was smaller. Conclusions: Care should be taken when interpreting the absolute ICC values, i.e., a higher ICC does not necessarily mean less variability because the ICC values can also be affected by various factors. The authors recommend that researchers clarify ICC models used and ICC values are interpreted in the context of measurement.