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

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.

Objective To assess differences in body composition according to gross motor function in children with cerebral palsy (CP) compared with healthy controls. Design Retrospective case-control study. Setting Tertiary referral center for CP. Participants Participants (N=146) comprised consecutive patients with CP (n=100; mean age, 11.5±4.2y) who were admitted for orthopedic surgery between May 2014 and March 2016 and typically developing children (TDC, n=46; control group). Interventions Not applicable. Main Outcome Measures Bioelectrical impedance analysis (BIA) was used to assess body composition, including body fat, soft lean mass (SLM), fat-free mass (FFM), skeletal muscle mass (SMM), body cell mass (BCM), bone mineral content (BMC), and basal metabolic rate. Body composition measures were compared according to Gross Motor Function Classification System (GMFCS) level, as well as between children with CP and TDC. Results Children with CP with GMFCS levels IV and V had a lower height, weight, and body mass index than those with GMFCS levels I to III. Children with CP with GMFCS levels IV and V had a significantly lower SLM, SLM index, FFM, FFM index, SMM, SMM index, BCM, BCM index, BMC, and BMC index than those with GMFCS levels I to III and TDC. GMFCS level significantly affected SLM and BMC. Conclusions Body composition analysis using BIA showed that nonambulatory children with CP had significantly lower FFM, SLM, SMM, BCM, and BMC than ambulatory children with CP and TDC. However, further study is required to allow the use of BIA as a valid nutritional assessment tool in patients with CP.

Objective Among the causes of limping gait in children, septic arthritis (SA) and transient synovitis (TS) are the 2 most likely etiologies. The aim of this study was to determine the medical histories, physical examinations, and other studies to use to create a clinical guideline for differential diagnosis between SA and TS in children in the emergency department (ED). The pediatric orthopedic emergency committee of our institution addressed the issue of developing a guideline for differential diagnosis. Methods Two rounds of the modified Delphi survey were conducted, and a face-to-face committee meeting was held after each survey round. Delphi survey panelists included 10 pediatric orthopedic surgeons and 8 emergency physicians including 3 pediatric emergency physicians. Results Response rates were 100% in each round. The panelists used a 6-point Likert scale to rate the clinical diagnostic guideline contents as having high (5 or 6), moderate (3 or 4), or low importance (1 or 2). Twenty-eight questionnaire items were included in the first round; and 18 items, in the second round. Factors for concern were selected, and a flowchart of the diagnostic guideline development process was based on the results of the survey. Conclusion A diagnostic guideline for evaluating SA and TS in children in the ED was achieved using combined empirical evidence together with expert opinion, potentially resulting in a diagnostic strategy to be incorporated into existing guidelines or used on its own.

Aim We aimed to evaluate the bone mineral density of the hip joint in patients with cerebral palsy (CP). Method Patients with CP younger than 18 years who underwent three-dimensional hip examination by computed tomography were analysed. Bone attenuation of the acetabulum and femur was measured as Hounsfield units (HU), and was adjusted for affecting factors such as hip instability and Gross Motor Function Classification System (GMFCS). Results One hundred and twenty-six patients with CP and 86 typically developing participants were included. The average bone attenuation was significantly lower in those with CP than in the comparison group (acetabulum: 70.8HU, 95% confidence interval [95% CI] 59.9–81.8; femur: 82.2HU, 95% CI 70.4–95.8). Compared with GMFCS levels I to III, bone attenuation was significantly lower for GMFCS levels IV (acetabulum: 30.9HU, 95% CI 15.7–46.2; femur: 39.7HU, 95% CI 19.9–59.5) and V (acetabulum: 51.7HU, 95% CI 35.9–67.5; femur: 72.5HU, 95% CI 51.9–93.0). The average bone attenuation decreased when the migration percentage was over 37% (acetabulum: 11.6HU, 95% CI 1.4–24.6; femur: 26.8HU, 95% CI 9.9–43.6). Interpretation Bone attenuation of the acetabulum and femur was significantly affected both by GMFCS level and by severity of hip instability.

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.

Objectives Seoul National University Bundang Hospital, which is the first Stage 7 hospital outside of North America, has adopted and utilized an innovative and emerging information technology system to improve the efficiency and quality of patient care. The objective of this paper is to briefly introduce the major components of the SNUBH information system and to describe our progress toward a next-generation hospital information system (HIS). Methods SNUBH opened in 2003 as a fully digital hospital by successfully launching a new HIS named BESTCare, "Bundang hospital Electronic System for Total Care". Subsequently, the system has been continuously improved with new applications, including close-loop medication administration (CLMA), clinical data warehouse (CDW), health information exchange (HIE), and disaster recovery (DR), which have resulted in the achievement of Stage 7 status. Results The BESTCare system is an integrated system for a university hospital setting. BESTCare is mainly composed of three application domains: the core applications, an information infrastructure, and channel domains. The most critical and unique applications of the system, such as the electronic medical record (EMR), computerized physician order entry (CPOE), clinical decision support system (CDSS), CLMA, CDW, HIE, and DR applications, are described in detail. Conclusions Beyond our achievement of Stage 7 hospital status, we are currently developing a next-generation HIS with new goals of implementing infrastructure that is flexible and innovative, implementing a patient-centered system, and strengthening the IT capability to maximize the hospital value.

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.

The pathogenic mechanism responsible for congenital pseudarthrosis of the tibia (CPT) is not well understood although the possibility of double inactivation of the neurofibromatosis type 1 (Nf1) gene has been suggested. In the present study, loss of heterozygosity was investigated in fibrous hamartoma tissues harvested from 16 patients with CPT associated with NF1 using four genetic markers that span the Nf1 gene. Based on the assumption that a single cell with double inactivation of Nf1 would undergo clonal growth and cause fibrous hamartoma, we investigated clonality in fibrous hamartoma tissues by analyzing X-chromosome inactivation patterns in 11 female patients. Loss of Nf1 heterozygosity in fibrous hamartoma tissues was observed at one or two genetic markers in 4 out of the 16 patients tested. In clonality assays, 3 of 11 patients showed a clonal growth pattern, 5 a non-clonal pattern, and 3 were non-informative. These findings support that double inactivation of the Nf1 gene and subsequent clonal growth could be a pathogenic feature of the fibrous hamartoma tissue at least in some of the CPT but might not be essential requirements of CPT development. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1535–1540, 2012

The choice of pinning techniques in supracondylar fractures of the humerus in children has been a debate regarding its fixation stability and risk of iatrogenic ulnar nerve palsy. This study was performed to determine as to which fixating method (medial and lateral crossed pinning vs. lateral pinning) is better for the displaced supracondylar fractures using a decision analysis tool in terms of function.A decision analysis model was designed containing the probability of iatrogenic ulnar nerve palsy and malunion caused by unstable fixation for each of lateral pinning and medial and lateral crossed pinning techniques. The final outcome was function adjusted life year and used as a utility in the decision tree, where function was evaluated using the McBride disability evaluation. The probabilities of all cases were obtained by literature review and assumptions. A roll back tool was used to determine the better pinning technique, and sensitivity analysis was performed to compensate for the uncertainty of the model.Overall, our decision model favored the lateral pinning technique over the medial and lateral crossed pinning with the utilities of 99.6 and 99.3 in terms of function adjusted life year. One-way sensitivity analysis showed that the threshold rate of iatrogenic ulnar nerve injury as a complication after medial and lateral crossed pinning was 0.7%, below which the model favored medial and lateral crossed pinning over lateral pinning. The decision model was found to be sensitive to the percentage of permanent ulnar nerve palsy after medial and lateral crossed pinning. Two-way sensitivity analysis showed that the lateral pinning technique was more beneficial than the medial and lateral crossed pinning technique.In our decision analysis model, the lateral pinning technique was found to be more beneficial than the medial and lateral crossed pinning technique for supracondylar fractures of the humerus in children, on the basis of current evidences. However, the results were sensitive to the data of ulnar nerve injury. Avoiding the worst clinical scenario (permanent ulnar nerve palsy) might be more important and affordable than obtaining favorable clinical results (stable fixation) at the potential cost of disastrous complications.Level III.

Background Although closed reduction and percutaneous pinning is accepted as the treatment of choice for displaced supracondylar fracture of the humerus, there are some debates on the pinning techniques, period of immobilization, elbow range of motion (ROM) exercise, and perceptions on the restoration of elbow ROM. This study was to investigate the consensus and different perspectives on the treatment of supracondylar fractures of the humerus in children. Methods A questionnaire was designed for this study, which included the choice of pinning technique, methods of elbow motion, and perception on the restoration of elbow ROM. Seventy-six orthopedic surgeons agreed to participate in the study and survey was performed by a direct interview manner in the annual meetings of Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand. There were 17 pediatric orthopedic surgeons, 48 hand surgeons, and 11 general orthopedic surgeons. Results Ninety-six percent of the orthopedic surgeons agreed that closed reduction and percutaneous pinning was the treatment of choice for the displaced supracondylar fracture of the humerus in children. They showed significant difference in the choice of pin entry (lateral vs. crossed pinning, p = 0.017) between the three groups of orthopedic surgeons, but no significant difference was found in the number of pins, all favoring 2 pins over 3 pins. Most of the orthopedic surgeons used a removable splint during the ROM exercise period. Hand surgeons and general orthopedic surgeons tended to be more concerned about elbow stiffness after supracondylar fracture than pediatric orthopedic surgeons, and favored gentle passive ROM exercise as elbow motion. Pediatric orthopedic surgeons most frequently adopted active ROM exercise as the elbow motion method. Pediatric orthopedic surgeons and general orthopedic surgeons acknowledged that the patient's age was the most contributing factor to the restoration of elbow motion, whereas hand surgeons acknowledged the amount of injury to be the most contributing factor. Conclusions More investigation and communication will be needed to reach a consensus in treating pediatric supracondylar fractures of the humerus between the different subspecialties of orthopedic surgeons, which can minimize malpractice and avoid medicolegal issues.

Aim This study was undertaken to determine the need for concurrent prophylactic femoral varization osteotomy (FVO) of contralateral stable hips at the time of hip reconstructive surgery on unstable hips in non-ambulant individuals with cerebral palsy (Gross Motor Function Classification System levels IV and V). Method A decision analysis model was constructed that included (1) the probability of unstable hips during observation of the contralateral stable hips, (2) unstable hip rate (subluxation or dislocation rate) after prophylactic FVO or after delayed reconstructive surgery (including FVO) for unstable hips, and (3) complication rates after concurrent prophylactic FVO or after hip reconstructive surgery. The final outcome score was based on pain utility measures. The probabilities of all cases and the utility score were obtained by literature review. Results The decision model favoured concurrent prophylactic FVO for the contralateral stable hips over observation (pain utility measure scores 0.814 vs 0.781). In a one-way sensitivity analysis, the decision model favoured concurrent prophylactic FVO when the unstable hip rate of contralateral stable hips during observation was 27% or over. Concurrent prophylactic surgery also demonstrated higher utility scores than observation when the unstable hip rate after FVO was between 0% and 29%. Interpretation The decision analysis model demonstrated that concurrent prophylactic FVO for a contralateral stable hip in individuals with cerebral palsy undergoing hip reconstructive surgery was beneficial from a medical perspective, which was based on current evidence.

Progression of hip displacement is common in patients with cerebral palsy (CP). We aimed to investigate the rate of progression of hip displacement in patients with CP by assessing changes in radiographic indices according to Gross Motor Function Classification System (GMFCS) level during hip surveillance. We analyzed the medical records of patients with CP aged < 20 years who underwent at least 6 months interval of serial hip radiographs before any surgical hip intervention, including reconstructive surgery. After panel consensus and reliability testing, radiographic measurements of migration percentage (MP), neck-shaft angle (NSA), acetabular index (AI), and pelvic obliquity (PO) were obtained during hip surveillance. For each GMFCS level, annual changes in radiographic indices were analyzed and adjusted for affecting factors, such as sex, laterality, and type of CP. A total of 197 patients were included in this study, and 1,097 radiographs were evaluated. GMFCS classifications were as follows: 100 patients were level I-III, 48 were level IV, and 49 were level V. MP increased significantly over the duration of hip surveillance in patients with GMFCS levels I-III, IV, and V by 0.3%/year (P < 0.001), 1.9%/year (P < 0.001), and 6.2%/year (P < 0.001), respectively. In patients with GMFCS level IV, NSA increased significantly by 3.4°/year (P < 0.001). Our results suggest that periodic monitoring and radiographic hip surveillance is warranted for patients with CP, especially those with GMFCS level IV or V. Furthermore, physicians can predict and inform parents or caregivers regarding the progression of hip displacement in patients with CP., Graphical Abstract

To determine whether changes in diffusion and/or contrast enhancement are of prognostic value in the early stage of Legg-Calvé-Perthes disease (LCPD).This study was approved by the institutional review board, and written informed consent was obtained from patient parents. Diffusion and contrast agent-enhanced magnetic resonance (MR) imaging studies were performed in 46 children (37 boys and nine girls; mean age, 7.5 years [age range, 3.3-11.9 years]) with unilateral LCPD at the early stage before development of extensive femoral head deformity. The degree of contrast enhancement was measured on the contrast-enhanced MR images, and the apparent diffusion coefficient (ADC) value was measured on the ADC map at various regions of interest in the proximal femur. The association of the MR imaging parameters that compared the affected side with the contralateral normal side with the femoral head deformity index value above 0.3 at 2 years was investigated.Increased diffusion in the metaphysis (P = .003) and decreased contrast enhancement in the central epiphysis (P = .034) were the significant prognostic indicators of subsequent femoral head deformation. ADC in the metaphysis 45% higher and a contrast enhancement in the central epiphysis 37% lower than those of the contralateral normal side are associated with a nonfavorable prognosis. For diffusion MR imaging, sensitivity was 83% (15 of 18), specificity was 86% (24 of 28), positive predictive value was 79% (15 of 19), negative predictive value was 89% (24 of 27), and accuracy was 85% (39 of 46). For contrast-enhanced MR imaging, sensitivity was 78% (14 of 18), specificity was 64% (18 of 28), positive predictive value was 58% (14 of 24), negative predictive value was 82% (18 of 22), and accuracy was 70% (32 of 46).Diffusion and contrast-enhanced MR imaging are potentially useful to assess risk of later development of femoral head deformity.

This study investigated the radiologic results of a stepwise surgical approach to equinocavovarus in 24 patients with cerebral palsy and determined the extent to which each procedure affected radiographic parameters using a linear mixed model. The anteroposterior talus-first metatarsal and anteroposterior talonavicular coverage angles were improved. The calcaneal pitch angle, tibiocalcaneal angle, lateral talus-first metatarsal angle, and naviculocuboid overlap were also improved. The Dwyer sliding osteotomy affected the tibiocalcaneal angle, whereas first metatarsal dorsal wedge osteotomy improved the calcaneal pitch angle and lateral first metatarsal angle. The stepwise surgical approach is effective for correction of equinocavovarus in cerebral palsy patients.

Congenital pseudarthrosis of the tibia (CPT) is a very rare but specific condition characterized by anterolateral bowing at birth, and recurrent pathologic fractures of the tibia during early childhood. Fracture usually occurs spontaneously or after minor trauma and rarely heals without appropriate surgical intervention, and easily results in pseudarthrosis. Fibrous hamartoma tissue is regarded as the key pathology of CPT,1) which occupies the site of pseudarthrosis, and is continuous with abnormally thickened periosteum in the adjacent bone segment. CPT frequently develops in patients with neurofibromatosis type 1 (NF1). It was reported that association with NF1 was found in 40 to 60 per cent of CPT patients,2) and CPT develops in 1 to 4 percent of patients with NF1.3) NF1 is one of the most common autosomal dominant disorders, affecting approximately 1 in 3500 births.4) It is characterized by neurofibromas, cafe-au-lait spots, Lisch nodules and numerous skeletal manifestations, such as macrocephaly, short stature, kyphoscoliosis, sphenoid wing dysplasia, congenital bowing and congenital pseudarthrosis of the tibia. NF1 is caused by a heterozygous mutation in the Nf1 gene located in chromosome 17q11.2.5) This gene encodes neurofibromin, which is expressed in a wide range of cells and tissues,6) including maturing chondrocytes, hypertrophic chondrocytes, osteoblasts, osteocytes, and osteoclasts.7) It is also expressed in tissues around CPT.8) Neurofibromin negatively regulates the activity of an intracellular signaling molecule p21ras (Ras), by functioning as a GTPase activating protein (Ras-GAP).9,10) Haploinsufficiency or complete deficiency in Nf1 gene function results in a dose-dependent elevation in Ras activity, which can activate the mitogen-activated protein kinase (MAPK) pathway and the phosphatidylinositol-3-phosphate kinase (PI-3K) pathway.11) The Nf1 gene is classified as a tumor suppressor gene. Heterozygous Nf1+/- mice experienced tumors and premature death.12) Chimeric mice containing moderate levels of Nf1-/- deficient cells went on to form numerous neurofibromas, which progressed to malignancy with loss of the p53 tumor suppressor gene.13) Furthermore, the loss of heterozygosity (LOH) is seen in benign and malignant tumors, including neurofibroma, malignant peripheral nerve sheath tumor (MPNST) and astrocytoma.14,15) Previous studies demonstrated that the phenotype of the fibrous hamartoma cells is consistent with the immunophenotype of mesenchymal lineage cells as that of tibial periosteal cells.16,17) However, these cells do not undergo osteoblastic differentiation in response to bone morphogenetic protein (BMP), and they are more osteoclastogenic than the tibial periosteal cells.16) In this study, we investigated further steps of osteoblastic differentiation in cells isolated from fibrous hamartoma, in order to delineate the mechanism of impaired osteoblastic differentiation of fibrous hamartoma cells.

Summary Objective Translation and transcultural adaptation of the Hip Disability and Osteoarthritis Outcome Score (HOOS LK 2.0) into Korean language was performed, followed by test of psychometric properties. Design A Korean version of the HOOS was produced according to internationally recommended guidelines, which included forward translation, reconciliation, back translation, harmonization, cognitive debriefing and proof reading. The psychometric properties including reliability and validity were evaluated. The reliability, including the internal consistency and test–retest reliability, was then evaluated in a hip osteoarthritis population (OA group, n =75). The validity, including the convergent validity was assessed comparing HOOS with the Short Form-36 (SF-36) and pain on a visual analogue scale (VAS) scale. Responsiveness was evaluated in a population scheduled for total hip arthroplasty (THA group, n =35). Results All subscales of the HOOS showed satisfactory internal consistency (Cronbach's alpha>0.7) without floor and ceiling effects. Intraclass correlation coefficient (ICC) spanned from 0.78 to 0.93. In terms of convergent validity, Activity of Daily Living (ADL) subscale showed the strongest correlations with Physical Function (PF) ( r =0.801) and Bodily Pain (BP) ( r =0.810) in the subscales of SF-36. For responsiveness, all HOOS subscale scores improved significantly ( P Conclusions The Korean version of HOOS showed satisfactory internal consistency, test–retest reliability, convergent validity, and responsiveness. This study shows that the HOOS questionnaire developed in West is, with transcultural adaptation, relevant for use among patients in East Asia.

A questionnaire survey was performed to investigate the different knowledge of radiation exposure, awareness and expectation for O-arm imaging system between the users (orthopaedic surgeons) and the developers (engineers). A total of 93 orthopaedic surgeons and 19 engineers participated and answered the questionnaire consisting of 18 items designed for this study. The items were focused on knowlege, awareness, and expectation. Orthopaedic surgeons had higher scores for items of knowledge domains regarding radiation exposure than the engineers while the engineers were more sensitive to radiation hazards and adopted higher levels of radiation protection t han orthopaedic surgeons in the awareness domain. Most engineers and orthopaedic surgeons answered that the requirements of diagnostic and intraoperative imaging systems differ. Image resolution, a low radiation exposure, and the time required for image acquisition was the top three requirements of O-arm selected by engineers. On the other hand, the top three requirements according to orthopaedic surgeons were; image resolution, expediency, and spatial occupancy. User requirements need to be reflected in developing O-arm along with basic requirem ents such as image resolution and low radiation exposure.

BACKGROUND Translation and transcultural adaptation of the Pediatric Outcomes Data Collection Instrument (PODCI) into Korean language was performed, and the validity was tested. METHODS Korean version of PODCI was produced according to internationally accepted guideline, which included preparation, forward translation, reconciliation, back translation, review of back translation and harmonization, cognitive debriefing and review, and proof reading process. Eighty-two child controls (aged 5 to 10 y), 92 adolescent controls (aged 10 to 18 y), and 30 children with cerebral palsy (aged 5 to 10 y) undergoing single event multilevel surgery were included, and their parents also participated. Each subscale of Korean PODCI was tested in terms of internal consistency (Cronbach α), discriminant validity (difference of parental responses between child control and children with cerebral palsy), convergent validity (correlation between self-response and parental response in adolescent control), and responsiveness (postoperative changes of parental responses in children with cerebral palsy). RESULTS All subscales except pain/comfort showed sufficient internal consistencies (Cronbach α > 0.7). Upper extremity/physical function, transfer/basic mobility, sports/physical functioning, and global functioning subscales showed significant discriminant validity (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively). Correlation between self-response and parental response in adolescent controls were significant in all subscales, being highest in transfer/basic mobility subscale (r = 0.952, P < 0.001) and lowest in happiness subscale (r = 0.548, P < 0.001). Responsiveness was significant in transfer/basic mobility (P < 0.001), sports/physical functioning (P=0.001), and global functioning (P = 0.006) subscales after single event multilevel surgery. CONCLUSIONS Korean version of PODCI showed relevant internal consistency, discriminant validity, convergent validity, and responsiveness except for pain/comfort and happiness subscales. Care need to be taken when evaluating subjective measures, such as pain/comfort and happiness subscales. LEVEL OF EVIDENCE Diagnostic level I.

BACKGROUND This study was performed to determine changes in Pediatric Outcomes Data Collection Instrument (PODCI) scores after single-event multilevel surgery (SEMS), and to evaluate the relationship between the improvements of PODCI scores and parental satisfaction after SEMS. METHODS Demographic data, preoperative and postoperative PODCI, functional assessment questionnaire (FAQ) walking scales, and self-reported parental satisfaction with SEMS were obtained from 61 parents of ambulatory patients with cerebral palsy [40 male, 21 female, mean age 10 y 2 mo (SD 3 y 8 mo), mean follow-up 2 y 2 mo]. Postoperative improvements in each subscale of PODCI and FAQ were analyzed, and multiple regression analysis was performed to identify the factors that contributed significantly to postoperative parental satisfaction. Rasch analysis was performed for the PODCI subscale that was clinically relevant. RESULTS FAQ, transfers/basic mobility, sports/physical activity, and global function subscales of PODCI significantly improved after SEMS. Age, gross motor function classification system level, and the amount of improvement in sports/physical activity subscale were found to affect parental satisfaction to SEMS significantly. However, the subscale showed insufficient item responses, and ceiling and floor effects. CONCLUSIONS Although changes in sports/physical activity subscale were relatively small, they were found to affect parental satisfaction with SEMS significantly. These indicate that clinicians and researchers should pay attention to sports and physical activities in patients with cerebral palsy. LEVEL OF EVIDENCE Diagnostic level I.

Patellar height is associated with various clinical syndromes. We asked which of three methods was the most appropriate for measuring patellar height for different age groups in terms of applicability, validity, and reliability. We evaluated 108 children and adolescents with available MR images and lateral knee radiographs using Insall-Salvati (IS), Blackburne-Peel, and Koshino-Sugimoto (KS) methods. Subjects were divided equally into three age groups (A, 5–10.9 years; B, 11–12.9 years; C, 13–18 years). The applicabilities of the three methods were evaluated using bony landmarks identified on lateral radiographs. For validation testing, standardized patellar tendon lengths determined by MRI were used as reference standards, and concurrent validity was analyzed by performing correlation tests. Intraobserver and interobserver reliability were determined using intraclass correlation coefficients. Of the three methods used to measure patellar height in this study, the IS appeared to be the most reliable and valid in patients older than 13 years with nearly complete ossification. Before this stage of ossification had been achieved, the KS was the only applicable and most reliable but less valid method in younger children. Level of Evidence: Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

To investigate the prevalence of hip osteoarthritis (OA) in a community-based elderly Korean population and to identify its risk factors.Radiographs of hip and knee were evaluated in 288 men and 386 women (ageor=65 years) that participated in the Korean Longitudinal Study on Health and Aging (KLoSHA). Minimum joint space widths (JSW), center-edge angles (CEA), and neck-shaft angles were measured on hip radiographs, and tibio-femoral angles on knee radiographs. Hip OA was defined as minimum JSW ofor=2mm oror=2.5mm. The following potential risk factors of OA were examined; demographic data, acetabular dysplasia, large CEA (or=40 degrees) and deformities of femoral neck and knee joint. Multivariate analysis with generalized estimating equation (GEE) model was performed to exclude confounding factors.When hip OA was defined as JSWor=2mm, the overall prevalence of the disease was 2.1% (95% confidence interval [CI], 1.0-3.2%), and only older age (or=70 years) was identified as a significant risk factors with an odds ratio (OR) of 10.0. However, when hip OA was defined as a JSW ofor=2.5mm, the overall prevalence of the disease was 13.1% (95% CI, 10.5-15.6%), and older age (or=70 years), female, large CEA (or=40 degrees), and acetabular dysplasia (CEA20 degrees) were identified as significant risk factors with ORs of 2.1, 2.1, 2.3, and 10.2, respectively.The prevalence of hip OA in elderly Korean was 2.1% (JSWor=2mm) in community-based population. Older age (or=70 years), female, large CEA (or=40 degrees), and acetabular dysplasia (CEA20 degrees) appeared to be significant risk factors of hip OA.

This study was undertaken to determine the effect of distal hamstring lengthening (DHL) on hip and knee sagittal kinematics, and to investigate the validity of modeled hamstring length for clinical use. Patient group consisted of 28 patients (56 limbs, mean age 7.4 years) with spastic diplegia who underwent bilateral DHL and tendo-Achilles lengthening with/without rectus femoris transfer (RFT) (DHL + RFT subgroup, 40 limbs; DHL subgroup, 16 limbs). Kinematic data was obtained by gait analysis, and hamstring lengths were obtained using a musculoskeletal modeling technique. Postoperatively, knee extension improved (p < 0.001) without aggravating anterior pelvic tilt (p = 0.565). However, DHL aggravated anterior pelvic tilt in the DHL subgroup (2.28, p = 0.011). In terms of concurrent validity, hamstring length was found to be correlated with mean pelvic tilt (r = 0.798, p < 0.001) and popliteal angle (r = 0.425, p = 0.001), but the correlation between hamstring length and knee flexion at initial contact was minimal (r = 0.068, p = 0.753). In terms of construct validity, DHL did not lengthen mean hamstring length (p = 0.918). In conclusion, DHL appeared to significantly improve knee motion in patients with spastic diplegia. Furthermore, DHL did not increase pelvic tilt, when performed with RFT. Modeled hamstring length is believed to have limited validity in patients with cerebral palsy, because it does not reflect knee kinematics or postoperative change when DHL was combined with multilevel surgery.

We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage. At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012). Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.

BACKGROUND This study was performed to identify issues of concern to parents after single-event multilevel surgery in ambulatory patients with cerebral palsy. METHODS Parents' reports of concern were obtained for 72 ambulatory patients with hemiplegic cerebral palsy (group H; mean age 8.7 y) and 170 ambulatory patients with diplegia (group D; mean age 8.9 y), who had undergone single-event multilevel surgery and were followed for more than 1 year (mean follow-up 5.5 y). Data were acquired using a postal survey. Issues of concern to parents were evaluated using a 5-point Likert scale (1 to 5) for each of 33 items, which was designed for this study. RESULTS The top 3 issues of concern after surgery were unequal limb circumference, the operative scar, and recurrence in group H, and the operative scar, play activity, and recurrence in group D. Overall concerns were greater in group D (P=0.001) whereas group H was more concerned about appearance such as unequal leg length and circumference (P=0.001

The effects of bone turnover rate on subchondral trabecular changes and cartilage destruction were evaluated in an iodoacetate-induced osteoarthritis rat model. Thirty female rats were randomly divided into three groups as the ovariectomized group, the no-treatment group and the bisphosphonate medication group. Arthritis was induced by a single intra-articular iodoacetate injection into the right tibiofemoral joint. Eight weeks after this injection, tibiofemoral joints on both sides were scanned with a micro-CT. Subchondral trabecular indices were measured on both sides of the tibial lateral condyle epiphysis. In the ovariectomized group, the percentage of bone volume, trabecular thickness and trabecular bone pattern factor of the arthritic sides were lower than those of the control sides, while trabecular separation and structure model index of the arthritic sides were higher than those of the control sides (p < 0.05). In the no-treatment group, only trabecular thickness of the arthritic sides was lower than in the control sides (p < 0.05). In the bisphosphonate medication group, trabecular indices were no different between the arthritic and control sides. Articular cartilage destruction and severity of arthritis increased significantly in the order: ovariectomized group < no-treatment group < bisphosphonate medication group (p < 0.05). After osteoarthritis development, severities of subchondral trabecular changes appeared to be strongly affected by bone turnover rate. Furthermore, a correlation was found between cartilage destruction severity and subchondral trabecular change in the intra-articular iodoacetate-injected osteoarthritis rat model.

Background Few data are available concerning the indications, outcomes, or optimum timing of femoral osteochondroplasty in patients with late sequelae of septic arthritis of the hip. Methods This paper presents 2 unusual cases of Choi type II sequelae associated with a large osteocartilaginous prominence or bump of the femoral head, responsible for cam-type femoroacetabular impingement in preadolescence. Results Two active preadolescents presented with groin pain after activity, a slightly antalgic gait, and difficulty squatting fully. On physical examination, both had less than 20 degrees of internal rotation with the hip in 90 degrees of flexion and a positive impingement sign, whereby groin pain was provoked by hip flexion, adduction, and internal rotation. One patient underwent osteochondroplasty and femoral valgus osteotomy, and the other osteochondroplasty alone, through surgical dislocation. Postoperatively, both had markedly improved free hip motion and no impingement sign. Conclusions Patients with type II sequelae before reaching skeletal maturity may present with femoroacetabular impingement symptoms. These 2 cases show that impingement-free hip motion through surgical dislocation improves symptoms. Level of Evidence Retrospective study, level IV.

BACKGROUND The shape of the dysplastic acetabulum has been generally determined by 2-dimensional computed tomography (CT) measurements (transaxial CT indices), such as the anterior and posterior acetabular indices and acetabular anteversion. However, their reliability and validity in evaluating the acetabular coverage have not been confirmed. METHODS This study examined the reliability and validity of the transaxial CT indices using 2- and 3-dimensional CT analyses of the acetabulum before and after a Dega osteotomy. Twenty-two acetabuli from 16 patients with cerebral palsy with hip instability were examined. Interobserver and intraobserver reliability tests were performed, and the preoperative and postoperative measurements were compared for the concurrent and construct validity test. RESULTS The transaxial CT indices revealed substantial intraobserver and interobserver reliability. The concurrent validity of the anterior acetabular and posterior acetabular indices before osteotomy was moderate (r = 0.45, 0.49), whereas the construct validity after osteotomy was low when compared with 3-dimensional methods. CONCLUSION The transaxial CT indices are reliable and valid for assessing the acetabular coverage in the preoperative status. However, care should be taken when using these indices to assess the outcome of a pelvic-reshaping osteotomy because of their insufficient construct validity. LEVEL OF EVIDENCE Level III of diagnostic study.

Fibrous hamartoma is a key pathologic component of congenital pseudarthrosis of the tibia, a challenging and disabling bone disorder. We investigated the biologic characteristics of fibrous hamartoma cells in order to better understand the pathogenesis of this rare disease.Fibrous hamartoma tissues were surgically excised at the time of osteosynthesis from seven patients with congenital pseudarthrosis of the tibia associated with neurofibromatosis type 1. Distal tibial periosteum was also harvested as control tissue during tibial derotation osteotomy from two other patients with cerebral palsy and one patient with idiopathic internal tibial torsion. Fibroblast-like cells were enzymatically dissociated and cultured from these tissues. Immunophenotypes were investigated for positive (CD44 and CD105) and negative (CD45 and CD14) mesenchymal lineage cell markers, and the mRNA expressions of bone morphogenetic protein(BMP)-2, BMP-4, and their receptors were assayed by reverse transcription-polymerase chain reaction. After rhBMP-2 treatment, the changes in alkaline phosphatase activity, and in the mRNA expressions of type-I collagen (COL1A1), alkaline phosphatase, and osteocalcin genes, were assayed with use of an RNase protection assay. The mRNA expressions of receptor activator of nuclear factor-kappa B ligand (RANKL) and osteoprotegerin (OPG) were quantitatively assayed with use of real-time RT-PCR. Osteoclastic differentiation of RAW(264.7) cells in coculture with fibrous hamartoma cells was evaluated.All fibrous hamartoma and tibial periosteal cells tested were CD44+/CD105+/CD45-/CD14- and expressed the mRNAs of BMP-2, BMP-4, and their receptors. The baseline mRNA expressions of COL1A1, alkaline phosphatase, and osteocalcin genes in the fibrous hamartoma cells were diverse. These gene expressions were upregulated by BMP treatment in tibial periosteal cells but did not change or were downregulated in fibrous hamartoma cells. Fibrous hamartoma cells expressed higher levels of RANKL and lower levels of OPG than did tibial periosteal cells. Coculture with fibrous hamartoma cells enhanced osteoclastic differentiation of RAW(264.7) cells.Fibrous hamartoma cells maintain some of the mesenchymal lineage cell phenotypes, but do not undergo osteoblastic differentiation in response to BMP. They are more osteoclastogenic than are tibial periosteal cells.

Background: Intramedullary fixation with use of a telescopic rod with a T-piece is one of the standard methods for long-bone stabilization in growing children with osteogenesis imperfecta. However, installation and removal of this device can cause substantial damage to the distal joint, which limits its use, especially in the tibia. We devised a modification of the telescopic rod system—the interlocking telescopic rod—in which the obturator is a simple rod with a hole, instead of a T-piece, at its distal end. Methods: The clinical and radiographic outcomes were evaluated more than two years following treatment of thirty-two limb segments (twenty-three tibiae and nine femora) with this new rod system in fifteen patients with osteogenesis imperfecta. Results: All rods were inserted without an arthrotomy of the distal joint, and all telescoped successfully. The interlocking pin used in the first five limb segments backed out between five and thirty-three months postoperatively. A revised fixation technique was used in the remaining twenty-seven limb segments, and the interlocking pin had not backed out at an average 3.1 years postoperatively. Proximal migration of the obturator was observed in four tibiae after 2.5 years. The cumulative survival rate of the rod at four years postoperatively was 88.7%. Conclusions: Both insertion and removal of an interlocking telescopic rod are much less invasive than insertion and removal of a conventional telescopic rod with a T-piece anchor. The interlocking pin at the distal epiphysis provides effective anchorage for telescoping. Our interim results showed survival of the device to be comparable with, or better than, that of the conventional telescopic rod. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Background:Ankle injuries associated with tibial shaft fractures can cause postoperative ankle pain and stiffness even when satisfactory bony union has been achieved. Although several previous studies have described these injuries, they have not been clearly defined or classified in terms of ankle injury type or need for surgical fixation.Methods:Seventy-one consecutive patients (mean ± SD age, 48.3 ± 16.7 years; 37 men and 34 women) with tibial shaft fractures who underwent computed tomography examination were included. Data were collected including age, sex, body mass index, fracture location of the tibia and fibula (in percentile of length), tibial fracture shape (spiral, oblique, transverse), presence and pattern of concomitant ankle injuries (on the distal tibial articular surface), and necessity for surgical fixation of ankle injuries. Factors associated with concomitant ankle injuries associated with tibial shaft fractures were analyzed by logistic regression analysis.Results:A total of 47 (64.7%) of the 71 tibial shaft fractures involved concomitant ankle injuries, including 8 cases of combined lateral malleolar fracture, posterior malleolar fracture, and anterior inferior tibiofibular ligament (AITFL) avulsion fracture; 9 cases of combined posterior malleolar fracture and AITFL avulsion fracture; 6 cases of combined lateral malleolar fracture and posterior malleolar fracture; 1 case of combined lateral malleolar fracture and AITFL avulsion fracture; 10 cases of posterior malleolar fracture; 7 cases of lateral malleolar fracture; 5 cases of AITFL avulsion fracture; and 1 unclassified fracture. Of these, 34 of the ankle injuries required surgical fixation. Spiral-type tibial shaft fracture was significantly associated with concomitant ankle injury ( P = .001).Conclusions:Orthopaedic surgeons should be aware that tibial shaft fractures, especially spiral-type fractures, are frequently associated with ankle injuries, such as lateral malleolar fractures, posterior malleolar fractures, and AITFL avulsion fractures. A considerable portion of these cases may necessitate surgical fixation. We recommend all spiral-type tibial shaft fractures routinely undergo computed tomography examination.Level of Evidence:Level III, comparative series.

Aim The aim of this study was to clarify the method of the Duncan-Ely test and to estimate its interobserver reliability and validity by comparing it with three-dimensional gait analysis (3DGA). Method This study included 36 consecutive ambulatory patients with cerebral palsy (CP) who underwent preoperative 3DGA. The Duncan-Ely test was performed during three different velocities (slow, gravity, and fast). The interobserver reliability was assessed by three examiners. The results of the test were compared with kinematic variables derived from the gait analysis to assess the sensitivity and specificity of the test. The cut-off value was determined at the point of trade-off between the highest sensitivity and specificity. Results The intraclass correlation coefficient measuring interobserver reliability of the Duncan-Ely test was greatest during fast velocity (0.819). The sensitivity and specificity of the test during gravity velocity for knee range of motion total were 63.0% and 100% respectively, with a cut-off value of 78.3°. The sensitivity and specificity of the test during fast velocity for knee range of motion total were 66.7% and 100% respectively, with a cut-off value of 65°. Interpretation The Duncan-Ely test shows excellent reliability in fast knee-flexion velocity, and good sensitivity and specificity compared with 3DGA during physical examination as a preoperative assessment of rectus femoris spasticity in patients with CP.

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

The T score represents the degree of deviation from the peak bone mineral density (BMD) (reference standard) in a population. Little has been investigated concerning the age at which the BMD reaches the peak value and how we should define the reference standard BMD in terms of age ranges. BMDs of 9,800 participants were analyzed from the Korean National Health and Nutrition Examination Survey database. Five reference standards were defined: (1) the reference standard of Japanese young adults provided by the dual-energy X-ray absorptiometry machine manufacturer, (2) peak BMD of the Korean population evaluated by statistical analysis (second-order polynomial regression models), (3) BMD of subjects aged 20–29 years, (4) BMD of subjects aged 20–39 years, and (5) BMD of subjects aged 30–39 years. T-scores from the five reference standards were calculated, and the prevalence of osteoporosis was evaluated and compared for males and females separately. The peak BMD in the polynomial regression model was achieved at 26 years in males and 36 years in females in the total hip, at 20 years in males and 27 years in females in the femoral neck, and at 20 years in males and 30 years in females in the lumbar spine. The prevalence of osteoporosis over the age of 50 years showed significant variation of up to two fold depending on the reference standards adopted. The age at which peak BMD was achieved was variable according to the gender and body sites. A consistent definition of peak BMD needs to be established in terms of age ranges because this could affect the prevalence of osteoporosis and healthcare policies.

This study was performed to measure the equivalent scattered radiation dose delivered to susceptible organs while simulating orthopaedic surgery using conventional and mini C-arm fluoroscopy. In addition, shielding effects on the thyroid, thymus, and gonad, and the direct exposure delivered to the patient’s hands were also compared. A conventional and mini C-arms were installed in an operating room, and a hand and an operator phantom were used to simulate a patient’s hand and a surgeon. Photoluminescence dosimeters were used to measure the equivalent dose by scattered radiation arriving at the thyroid, thymus, and gonad on a whole-body phantom in the position of the surgeon. Equivalent scattered radiation doses were measured in four groups: (1) unshielded conventional C-arm group; (2) unshielded mini C-arm group; (3) lead-shielded conventional C-arm group; and (4) lead-shielded mini C-arm group. Equivalent scattered radiation doses to the unshielded group were significantly lower in the mini C-arm group than those in the conventional C-arm group for all organs. The gonad in the lead-shielded conventional C-arm group showed the highest equivalent dose among operator-susceptible organs, and radiation dose was reduced by approximately 96% compared with that in the unshielded group. Scattered radiation was not detected in any susceptible organ in the lead-shielded mini C-arm group. The direct radiation dose to the hand phantom measured from the mini C-arm was significantly lower than that measured from the conventional C-arm. The results show that the equivalent scattered radiation dose to the surgeon’s susceptible organs and the direct radiation dose to a patient’s hand can be decreased significantly by using a mini C-arm rather than a conventional C-arm. However, protective lead garments, such as a thyroid shield and apron, should be applied to minimize radiation exposure to susceptible organs, even during use of mini C-arm fluoroscopy.

Purpose To investigate the clinical and radiologic outcomes and prognostic factors of arthroscopic partial meniscectomy with or without suture repair of the remnant rim and subtotal meniscectomy in children with discoid menisci. Methods We retrospectively reviewed all consecutive patients aged younger than 18 years who underwent arthroscopy between 2003 and 2012, excluding patients with follow-up less than 2 years, concomitant injuries, underlying diseases, or a lost videotape. Patients were grouped by treatment method: partial meniscectomy with or without suture repair and subtotal meniscectomy. Clinical outcomes were determined based on symptoms, complications, and Lysholm scores. Degenerative changes were assessed radiologically. Risk factors for a lower Lysholm score were investigated. Results Of 100 knees (86 patients; mean age, 10.7 years), 87 underwent partial meniscectomy with (n = 42) or without (n = 45) suture repair and 13 underwent subtotal meniscectomy. The Lysholm score at a mean of 4.7 years (range, 2.0 to 10.9 years) improved to more than 90, regardless of meniscectomy method ( P = .767; 95% confidence interval [CI], –5.1 to 6.9) or the addition of suture repair ( P = .797; 95% CI, –3.5 to 4.6). Early degenerative changes were found in 11 knees. Patients aged younger than 10 years at surgery had a 2.37 times higher chance of having excellent Lysholm scores ( P = .032; 95% CI, 1.1 to 5.1). A reoperation history was associated with lower Lysholm scores with a marginal significance ( P = .054; 95% CI, –0.9 to 12.3). Conclusions Arthroscopic partial meniscectomy with stabilization of the unstable remnant rim was effective in preserving knee function with few early degenerative changes during the midterm follow-up period. Subtotal meniscectomy appears to be a valid treatment for unsalvageable cases. There was no difference in outcomes among the partial meniscectomy, partial meniscectomy with suture repair, and subtotal meniscectomy groups. Less satisfactory functional outcomes may follow in children aged 10 years or older or when a reoperation has been performed. Level of Evidence Level IV, therapeutic case series.

This study investigates the overall rate of urinary retention in a large cohort of unselected orthopaedic patients who had either general or regional anesthesia and defines the risk factors for postoperative urinary retention in that cohort of patients. A total of 15,681 patients who underwent major orthopaedic surgery with general or spinal/epidural anesthesia were included. Postoperative urinary retention was defined as any patient who required a postoperative consultation to the urologic department regarding voiding difficulty. Age at surgery, sex, type of surgery, medical history including hypertension and diabetes mellitus, and type of anesthesia were analyzed as potential predictor variables. There were 365 postoperative patients who required urology consults for urinary retention (2.3%). Older age at surgery (OR, 1.035;P<0.0001), male sex (OR, 1.522;P=0.0004), type of surgery (OR, 1.506;P=0.0009), history of hypertension (OR, 1.288;P=0.0436), and history of diabetes mellitus (OR, 2.038;P<0.0001) were risk factors for urinary retention after orthopaedic surgery. Advanced age, male sex, joint replacement surgery, history of hypertension, and diabetes mellitus significantly increased the risk of urinary retention. In patients with these risk factors, careful postoperative urological management should be performed.

The purposes of this study were to determine the clinical course of isolated congenital pseudarthrosis of the fibula (ICPF) and to establish optimal treatment guidelines for this disease. Thirteen fibulae in 12 patients with ICPF were followed for an average of 6.2 years. Twelve of the 13 fibulae were regarded to originally have had a pre-pseudarthrotic condition. Five fibulae remained intact during follow-up, but 8 developed pseudarthrosis. Two cases with established pseudarthrosis were observed for ankle alignment change without intervention, and in 4 cases successful fibular osteosynthesis maintained the ankle alignment. The remaining 2 adolescent cases presenting with ankle valgus were treated using the Ilizarov technique and distal tibiofibular synostosis. ICPF follows a unique clinical course, which should be taken into consideration along with fibular status, ankle alignment, and patient age when planning treatment.

A longitudinal study is among the most popular methods used to test hypotheses in orthopaedic research. However, clinical data analyses can present challenges in several situations. The following orthopaedic scenario will be used throughout this article; in this scenario, the data structure is longitudinal. A researcher evaluated the long-term outcomes of the Dega osteotomy1 in fifty patients (sixty hips) with symptomatic developmental dysplasia of the hip. The mean age at the time of the operation was thirty months, and the mean duration of follow-up was sixty months (range, twelve to 144 months). The clinical outcome was assessed with use of preoperative and postoperative radiographic evaluations of the acetabular index. The preoperative and postoperative radiographs were repeatedly assessed during the follow-up period. However, some patients may not have …

The authors studied the outcomes of calcaneal lengthening for the treatment of planovalgus foot deformity in ambulatory children with cerebral palsy (92 feet in 56 children, mean age 9.2 years), attempting to define the surgical indication in terms of the severity of the foot deformity. Sixty-nine cases (75%) showed satisfactory clinical outcomes at an average follow-up of 5.2 years (range 4.0-17.2 years). Gait parameters such as foot progression angle, ankle motion in sagittal plane, and its power generation improved after operation. Preoperative talocalcaneal angle, talo--first metatarsal angle, and calcaneal pitch on weight-bearing lateral radiographs were predictive of the satisfactory results of the index operation. The authors conclude that calcaneal lengthening is an effective procedure for moderate to severe planovalgus foot deformities in children with cerebral palsy, but there is a limit under which the index operation can be performed safely: less than 35 degrees of talocalcaneal angle, less than 25 degrees of talo--first metatarsal angle, and more than 5 degrees of calcaneal pitch on weight-bearing lateral radiographs.

Congenital diastasis of the inferior tibiofibular joint presents clinical problems of talipes equinovarus, ankle diastasis, and leg-length inequality. In the past, foot disarticulation and prosthetic fitting has often been chosen as a solution because of the difficulty involved in functional reconstruction. The authors report three additional cases of congenital diastasis of the inferior tibiofibular joint that were satisfactorily treated by lengthening of the tibia and fibula and foot repositioning by the Ilizarov technique. After treatment, all patients had a plantigrade, functional foot with normal sensation at skeletal maturity and were satisfied with the cosmetic and functional outcomes. The Ilizarov technique is effective in accomplishing the goals of leg-length equalization and foot repositioning.

The authors evaluated 14 patients with hypophosphatemic rickets who underwent correction of a knee deformity along with a leg lengthening by the Ilizarov method. Deformity correction alone was performed in 8 femora and 4 tibiae-fibulae, and concomitant deformity correction and limb lengthening (>1.0 cm) in 9 femora and 19 tibiae-fibulae. The healing index correlated with the biochemical parameters. Knee deformities were satisfactorily corrected in all patients except one. There was a statistically significant negative correlation between the healing index and the serum phosphate level: those who had a serum phosphate level higher than 2.5 mg/dL showed a relatively rapid regenerate bone healing compared with those with less than 2.5 mg/dL. The authors conclude that a serum phosphate level of 2.5 mg/dL as a cut-off point should be considered in deciding whether deformity correction alone or with a concomitant leg lengthening should be undertaken.

Category: Ankle Introduction/Purpose: The gastrocnemius, a biarticular muscle that crosses the knee and ankle, acts as a knee flexor as well as an ankle plantar flexor. Although simultaneous motion of the knee and ankle joints is required for many activities including standing, running, swimming, and cycling, the change in ankle motion during gait has not been described in patients with cerebral palsy who underwent distal hamstring lengthening or distal hamstring lengthening with rectus femoris transfer. Therefore, we aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in cerebral palsy patients. Methods: The analysis included data regarding 55 limbs from 34 patients with spastic cerebral palsy, who were followed-up after they had undergone distal hamstring lengthening with or without additional rectus femoris transfer. Mean age of the patients at time of the knee surgery was 11.2 ± 4.7 years. Preoperative and postoperative kinematic variables that were extracted from three-dimensional gait analyses were compared to assess the change in ankle motion after surgery involving tendons around the knee. The postoperative 3D gait analysis was performed at a mean of 0.9 ± 1.3 years after the surgery. The outcome measures were relevant kinematics parameters including peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle. A linear mixed model was constructed to estimate the changes in ankle motion after adjusting for multiple factors. Results: We estimated that peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4º (p=0.016), 0.6º (pConclusion: Improvement in total knee range of motion was correlated with a decrease in ankle kinematics after surgery involving tendons around the knee. Knee surgery may reduce the need for an additional surgical procedure involving the ankle joint. Because the simultaneous motion of the knee and ankle joints is cross-linked, surgeons should be aware of potential changes in the ankle joint after knee surgery.

Background: Injury mechanism and the amount of force are important factors determining whether a fracture or sprain occurs at the time of an ankle inversion injury. However, the anatomical differences between the ankle fracture and sprain have not been investigated sufficiently. This study was performed to investigate whether an anatomical predisposition of the ankle joint results in a lateral malleolar fracture or lateral ankle sprain. Methods: Two groups of consecutive patients, one with lateral malleolar fracture (274 patients, mean age 49.0 years) and the other with lateral ankle sprain (400 patients, mean age 38.4 years), were evaluated. Ankle radiographs were examined for 7 measures: distal tibial articular surface (DTAS) angle, bimalleolar tilt (BT), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), anterior inclination of tibia (AI), and fibular position (FP). After an interobserver reliability test, the radiographic measurements were compared between the 2 groups. Linear regression analysis was performed to correct for age and sex effects between the groups. Results: The fracture group and the sprain group showed significant differences in BT ( P = .001), MMSA ( P < .001), AI ( P = .023), and FP ( P < .001). In multiple regression analysis, after adjusting for age and sex effects, fracture and sprain groups showed a significant difference in BT ( P = .001), MMRL ( P < .001), MMSA ( P < .001), and FP ( P < .001). Conclusions: The lateral malleolar fracture group tended to show more bony constraint than that of the lateral ankle sprain group. Further 3-dimensional assessment of the bony structure and subsequent biomechanical studies are needed to elucidate the mechanism of injury according to the various types of ankle fractures and ankle sprain. Level of Evidence: Level III, retrospective comparative study.

Background Recurrence of equinus deformity after surgery is common in patients with cerebral palsy. This retrospective study was undertaken to estimate the recurrence rate of the equinus deformity after tendo-Achilles lengthening (TAL) in patients with cerebral palsy and to investigate the risk factors associated with the recurrence. Methods Two-hundred forty three ambulatory patients with cerebral palsy, who underwent TAL for equinus foot deformity since 1995, and had undergone a preoperative and postoperative 3-dimensional gait analysis, were included. Cox proportional hazards model was used to determine the significant contributing factor for the recurrence of equinus foot deformity. Results The mean patient age at surgery was 7.8±2.7 years and the mean follow-up duration was 8.1±3.4 years. Equinus deformity recurred in 22 of the 243 patients (9.1%) and the Kaplan-Meier survival estimate was shown to be 89.4% at 10 years not needing repeat surgery. According to the multivariate analysis using the Cox proportional hazard model, preoperative ankle dorsiflexion at initial contact (P=0.016) was the only significant factor for recurrence of equinus deformity after surgery. Age at surgery and the type of limb involvement were not associated with the recurrence (P=0.433 and 0.269). The cutoff values of preoperative gait kinematics between the nonrecurrence and recurrence groups were -19 degrees of ankle dorsiflexion at initial contact (P=0.018). Conclusions This study showed that the severity of preoperative equinus deformity was a risk factor associated with recurrence after TAL in patients with cerebral palsy. Therefore, surgeons should consider the recurrence and later revision surgery for the patients with severe equinus foot deformity. Level of evidence Therapeutic level III.

Background Percutaneous epiphysiodesis using transphyseal screws (PETS) has been used to manage leg length discrepancy (LLD) in growing children. The purposes of this study were to analyze effects of PETS on LLD, its associated complications, to determine optimal operation timing, and find ways of preventing complications. Patients and methods The data of 59 patients obtained up to screw removal or at skeletal maturity were retrospectively analyzed. Retrospective growth calculations were done using multiplier method. The efficacy of LLD correction was calculated, and the predicted segment length with the index operation was compared with the final measured length and final LLD was measured. The screw insertion angle in 3-dimension was calculated, and it was correlated with the efficacy. Complications associated with screw design and the techniques used were analyzed. Results The LLD correction efficacy averaged 75.5% (5.0 to 114.0) at the distal femur and 78.9% (11.0 to 111.0) at the proximal tibia. However, mean final LLD was 3.0 mm (range, -10.0 to 16.7 mm), presumably because operations were performed on average 1.3 years earlier than estimated by growth calculation. Three-dimensional screw insertion angle was positively correlated with LLD correction efficacy. Complications were closely related to the screw design and the implantation techniques. Conclusions PETS provides a minimally invasive and effective means of LLD correction. In view of its delayed effect, we recommend that PETS be performed at least 1 year earlier than estimated optimal epiphysiodesis timing. The careful selection of screw design and length and accurate screw placement are the keys to successful results. Level of evidence Level IV prognostic studies.

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