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The aim of this study was to translate and transculturally adapt the Caregiver PrioritiesChild Health Index of Life with Disabilities (CPCHILD) questionnaire into Korean language, and to test the reliability and validity, including the internal consistency, known-group validity and factor analysis of the Korean version of the CPCHILD.A Korean version of CPCHILD was produced according to internationally accepted guidelines. For validity testing, 194 consecutive parents or caregivers of children with cerebral palsy (CP) were recruited and completed the questionnaire. Internal consistency, test-retest reliability, and known-groups validity were evaluated and factor analysis was performed to validate the Korean version of the CPCHILD.In terms of internal consistency, a Cronbach's alpha was above 0.90 in all domains of the CPCHILD (range 0.921 to 0.966), except the 5th domain (0.628). In terms of known-groups validity, the total score of the CPCHILD was significantly different according to the Gross Motor Function Classification System (GMFCS) level (p 0.001). Intra-class correlation coefficient spanned from 0.517 to 0.801. Factor analysis showed that the five-factor solution of the CPCHILD explained 76.7% of the variance with 59.0, 6.5, 5.1, 4.2 and 3.2% of variance by each components number.The Korean version of CPCHILD was found to be a reliable and valid questionnaire of caregivers' perspectives on the health-related quality of life in severely affected children with CP. However, the Korean version of CPCHILD contains some redundant items, and factor analysis suggested a five-domain questionnaire. Implication for Rehabilitation The Korean version of CPCHILD is a reliable, internally consistent, valid instrument for assessing the health-related quality of life in severely affected children with CP from the perspective of caregivers. After the transcultural adaptation and validation of the Korean CPCHILD, it can be reliably used in clinical and research settings to evaluate the health-related quality of life in Korean patients with CP.

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.

Patients with cerebral palsy or arthritis have deformities in lower limb which cause unstable gait or posture and pains. Surgeons perform a deformity correction osteotomy with surgical plan. But sometimes they find the unexpected angular or rotational deformation after surgery. The problems are that there is no method to predict the result of a surgical plan and also there are so many factors to must consider in surgical planning step such as clinical measurements, rotation angle, wedge angle, morphology of lower limb, etc. This paper presents new methods for planning the deformity correction osteotomy efficiently. There are two approaches based on the 3D mesh model and the accurate assessment of the patient’s lower limb. One is the manual presimulation of surgery using forward kinematics. And the other is the automatic surgical planning using inverse kinematics and nonlinear optimization. Using these methods, we can predict and verify the results of various surgical treatments and also we can find a more effective surgical plan easily compared to conventional methods. 키워드: 정기구학, 역기구학,비선형최적화,하지변형,임상지표,수술시뮬레이션,수술계획

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.

This study aimed to investigate the effects of walking speed and slope on foot pressure changes in young healthy adults.Twenty young healthy adults (mean age 22.4 years, SD 1.2 years; 10 male and 10 female) participated in the study. Dynamic pedobarographic data during treadmill walking were obtained for combinations of three different walking speeds (3.2 km/hr, 4.3 km/hr, and 5.4 km/hr) and 5 different slopes (downhill 8 degrees, downhill 4 degrees, ground walking (0 degree), uphill 4 degrees, and uphill 8 degrees). Pedobarographic data such as the peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel. Maximum ankle dorsiflexion was also recorded using the Plug in Gait marker set.All participants maintained heel-toe gait in all walking conditions. The peak pressure on the MFF during downhill slope walking was lower than that during ground and uphill walking, whereas the peak pressure on the MFF during uphill slope walking was similar to that during ground walking at each walking speed. The peak pressures on the heel were similar for different walking slopes at each walking speed. The peak pressures on the MFF and heel increased with an increase in walking speed. The pressure-time integral of the MFF did not show significant changes at different walking speeds and slopes. The pressure-time integral of the heel increased with an increase in walking slope and decrease in walking speed.Different walking speeds and slopes affected the pedobarographic characteristics of young healthy adults. Downhill walking with slower speed appeared to be beneficial to reduce or optimize MFF pressures, while downhill walking at a comfortable speed would be helpful to reduce or optimize heel pressures. The findings of this study have clinical implications in recommending activities to patients with foot pressure-related symptoms and disorders.

BackgroundThis study aimed to investigate the effects of walking speed and slope on foot pressure changes in young healthy adults.MethodsTwenty young healthy adults (mean age 22.4 years, SD 1.2 years; 10 male and 10 female) participated in the study. Dynamic pedobarographic data during treadmill walking were obtained for combinations of three different walking speeds (3.2 km/hr, 4.3 km/hr, and 5.4 km/hr) and 5 different slopes (downhill 8 degrees, downhill 4 degrees, ground walking (0 degree), uphill 4 degrees, and uphill 8 degrees). Pedobarographic data such as the peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel. Maximum ankle dorsiflexion was also recorded using the Plug in Gait marker set.ResultsAll participants maintained heel-toe gait in all walking conditions. The peak pressure on the MFF during downhill slope walking was lower than that during ground and uphill walking, whereas the peak pressure on the MFF during uphill slope walking was similar to that during ground walking at each walking speed. The peak pressures on the heel were similar for different walking slopes at each walking speed. The peak pressures on the MFF and heel increased with an increase in walking speed. The pressure-time integral of the MFF did not show significant changes at different walking speeds and slopes. The pressure-time integral of the heel increased with an increase in walking slope and decrease in walking speed.ConclusionsDifferent walking speeds and slopes affected the pedobarographic characteristics of young healthy adults. Downhill walking with slower speed appeared to be beneficial to reduce or optimize MFF pressures, while downhill walking at a comfortable speed would be helpful to reduce or optimize heel pressures. The findings of this study have clinical implications in recommending activities to patients with foot pressure-related symptoms and disorders.

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.

Accurate quantification of bone morphology is important for monitoring the progress of bony deformation in patients with cerebral palsy. The purpose of the study was to develop an automatic bone morphology measurement method using one or two radiographs. The study focused on four morphologic measurements—neck-shaft angle, femoral anteversion, shaft bowing angle, and neck length. Fifty-four three-dimensional (3D) geometrical femur models were generated from the computed tomography (CT) of cerebral palsy patients. Principal component analysis was performed on the combined data of geometrical femur models and manual measurements of the four morphologic measurements to generate a statistical femur model. The 3D–2D registration of the statistical femur model for radiography computes four morphological measurements of the femur in the radiographs automatically. The prediction performance was tested here by means of leave-one-out cross-validation and was quantified by the intraclass correlation coefficient (ICC) and by measuring the absolute differences between automatic prediction from two radiographs and manual measurements using original CT images. For the neck-shaft angle, femoral anteversion, shaft bowing angle, and neck length, the ICCs were 0.812, 0.960, 0.834, and 0.750, respectively, and the mean absolute differences were 2.52°, 2.85°, 0.92°, and 1.88 mm, respectively. Four important dimensions of the femur could be predicted from two views with very good agreement with manual measurements from CT and hip radiographs. The proposed method can help young patients avoid instances of large radiation exposure from CT, and their femoral deformities can be quantified robustly and effectively from one or two radiograph(s).

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.

The present study evaluated the radiographic outcomes of syndesmosis injuries treated with a partially threaded 5.0-mm cannulated screw. The present study included 58 consecutive patients with syndesmosis injuries concurrent with ankle fractures who had undergone operative fixation with a partially threaded 5.0-mm cannulated screw to repair the syndesmosis injury. Radiographic indexes, including the medial clear space, tibiofibular overlap, tibiofibular clear space, and fibular position on the lateral radiograph, were measured on the preoperative, immediate postoperative, and final follow-up radiographs. The measurements were compared between the injured and intact ankles. All preoperative radiographic indexes, including the medial clear space (p .001), tibiofibular overlap (p .001), tibiofibular clear space (p .001), and fibular position on the lateral radiograph (p = .026), were significantly different between the injured and intact ankles. The medial clear space of the injured ankle was significantly wider than that of the intact ankle preoperatively (p .001) and had become significantly narrower immediately postoperatively (p .001). Finally, the medial clear space was not significantly different between the injured and intact ankles at the final follow-up examination (p = .522). No screw breakage or repeat fractures were observed. A 5.0-mm partially threaded cannulated screw effectively restored and maintained the normal relationship between the tibia and fibula within the ankle mortise with a low risk of complications. This appears to be an effective alternative technique to treat syndesmosis injuries concurrent with ankle fractures.

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.

Background Although ankle fracture surgery can affect glycemic control by either trauma-induced stress or a postoperative decrease in physical activity, there is little evidence on this issue. This study aimed to evaluate the influence of ankle fracture surgery on glycemic control and to assess the risk factors for poor glycemic control after surgery in patients with diabetes. Methods We reviewed the medical records of consecutive patients with diabetes who underwent open reduction and internal fixation for the treatment of ankle fracture at our hospital. Patients who underwent blood testing, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and cholesterol levels, as part of a routine check-up before surgery and again more than 2 times after surgery were included. Changes in blood test results were adjusted by multiple factors using a linear mixed model with sex, age at time of surgery, body mass index (BMI), and type of ankle fracture as the fixed effects and each subject and timing of blood test as the random effects. Results Sixty patients were ultimately included in this study. At 1 month postoperatively, mean FBG and cholesterol levels had increased significantly compared with preoperative levels (p = 0.011 and 0.024, respectively). After surgery, FBG levels showed an estimated monthly decrease of 2.2 mg/dL (p = 0.017). Sex, age at time of surgery, and type of ankle fracture did not significantly affect the monthly change in FBG level. FBG returned to the preoperative level at an estimated period of 8.1 months. BMI significantly affected preoperative FBG level (p = 0.015) but not the postoperative change in FBG level (p = 0.500). Conclusion Ankle fracture surgery increased the FBG level at 1 month postoperatively. FBG levels decreased gradually after surgery at an estimated monthly rate of 2.2 mg/dL. Physicians should be aware of the difficulty in postoperative blood glucose control in patients with diabetes, even several months after surgery.

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.

Objective Nearly a dozen reduction methods for the treatment of anterior shoulder dislocation have been reported, but the majority are painful and require patients to be in the supine or prone position. Methods This retrospective cohort study was conducted in a university-affiliated emergency department (ED). Sool's method and traditional shoulder reduction methods (TSRMs) were performed for the patient with anterior shoulder dislocation. Fifty-nine eligible patients were recruited; 35 were treated with TSRMs, wherease 24 were treated with Sool's method. Results The rate of successful reduction was 80% (26/35) in the TSRM group and 75% (18/24) in the Sool's method group ( P =.75). The length of stay in the ED was 72.3minutes in the Sool's method group and 98.4minutes in the TSRM group ( P =.037). No significant difference was observed between the neurovascular deficit before and after reduction in either group. The procedural time of successfully reduced cases in patients treated by Sool's method was shorter than that of the failed cases ( P =.015). Conclusions Sool's method was as successful as other methods at reducing shoulder dislocation and has demonstrated encouraging results, including significant reduction in length of stay in the ED and unnecessary use of sedation. Sool's method is technically easy and requires only a place to sit and a single operator.

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.

a b s t r a c t A variety of multi-walled carbon nanotubes grafted with immidazolium-based ionic liquids (CNT-ILs) were synthesized and utilized as highly efficient heterogeneous catalysts for the production of cyclic car- bonates via cylcoaddition reactions of epoxides and CO2. In comparison with conventional heterogeneous catalysts that employ porous silica and polymer supports, CNT-ILs exhibited significantly enhanced cat- alytic reactivity towards the cycloaddition reactions. The effects of the IL molecular structure (alkyl chain length and counter anions) and the reaction parameters (temperature, CO2 pressure, and time) on the cat- alytic performance of the corresponding heterogeneous catalysts were also systematically investigated.

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

Chemical Mechanical Planarization (CMP) is a polishing process used in the microelectronic fabrication industries to achieve a globally planar wafer surface for the manufacturing of integrated circuits. Pad conditioning plays an important role in the CMP process to maintain a material removal rate (MRR) and its uniformity. For metal CMP process, highly acidic slurry containing strong oxidizer is being used. It would affect the conditioner surface which normally made of metal such as Nickel and its alloy. If conditioner surface is corroded, diamonds on the conditioner surface would be fallen out from the surface. Because of this phenomenon, not only life time of conditioners is decreased, but also more scratches are generated. To protect the conditioners from corrosion, thin organic film deposition on the metal surface is suggested without requiring current conditioner manufacturing process. To prepare the anti-corrosion film on metal conditioner surface, vapor SAM (self-assembled monolayer) and FC (Fluorocarbon) -CVD (SRN-504, Sorona, Korea) films were prepared on both nickel and nickel alloy surfaces. Vapor SAM method was used for SAM deposition using both Dodecanethiol (DT) and Perfluoroctyltrichloro silane (FOTS). FC films were prepared in different thickness of 10 nm, 50 nm and 100 nm on conditioner surfaces. Electrochemical analysis such as potentiodynamic polarization and impedance, and contact angle measurements were carried out to evaluate the coating characteristics. Impedance data was analyzed by an electrical equivalent circuit model. The observed contact angle is higher than 90o after thin film deposition, which confirms that the coatings deposited on the surfaces are densely packed. The results of potentiodynamic polarization and the impedance show that modified surfaces have better performance than bare metal surfaces which could be applied to increase the life time and reliability of conditioner during W CMP.

A double metal cyanide (DMC) complex based on (Zn3[Co(CN)6]2), an effective catalyst for the ring opening polymerization of epoxides and the copolymerization of carbon dioxide with epoxides, was successfully utilized for the solvent-free cycloaddition of CO2 to styrene oxide (SO) by the introduction of cetyltrimethylammonium bromide (CTAB) as a complexing agent (CA). Several DMC catalysts were prepared by introducing co-complexing agents (co-CAs) along with the CA. From the XRD data, it was clear that all the catalysts were amorphous with no peak corresponding to the precursor ZnCl2. XPS analysis was performed to explain the successful introduction of the CA to the DMC catalyst, in which the binding energy of the zinc atom shifted from precursor ZnCl2 to DMC. Elemental analysis and FT-IR also confirmed the incorporation of the CA with Zn3[Co(CN)6]2. The DMC complex was proven to be an effective catalyst for the solvent-free synthesis of styrene carbonate by the cycloaddition of styrene oxide and CO2. This paper reports the tunability of the metal cyanide catalysts with CA for the selective preparation of cyclic carbonates over polycarbonates. 1H NMR and FT-IR confirmed product formation. The effects of reaction parameters like catalyst amount, temperature, CO2 pressure, and reaction time were also investigated.

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.

A variety of imidazolium-based ionic liquids (ILs) have been widely developed to effectively catalyze the cycloaddition reactions of CO2 and epoxides. To further improve the catalytic performance of those IL catalysts, we incorporated various metal chlorides (CoCl2, NiCl2, CuCl2, ZnCl2, and MnCl2) into silica-grafted 1-methyl-3-[(triethoxysilyl)propyl] imidazolium chloride to produce a series of heterogeneous catalysts. Catalytic reaction tests demonstrated that the incorporation of such metal ions can significantly enhance the catalytic reactivity of the silica-grafted ILs towards cycloaddition reactions of CO2 and epoxides that produce cyclic carbonates in solvent-free conditions. In addition, the effects on the catalytic reactivity of reaction parameters including reaction time, reaction temperature and CO2 pressure were investigated. We have explored to incorporate various metal chlorides (CoCl2, NiCl2, CuCl2, ZnCl2, and MnCl2) into silica-grafted 1-methyl-3-[(triethoxysilyl)propyl] imidazolium chloride to produce a series of heterogeneous catalysts. Catalytic reaction tests demonstrated that the incorporation of such metal ions can significantly enhance the catalytic reactivity of the silica-grafted ILs towards cycloaddition reactions of CO2 and epoxides that produce cyclic carbonates in solvent-free conditions.

In this study, a series of imidazolium-based ionic liquids (ILs) having carboxylic acid moieties were synthesized and used as new homogeneous catalysts to synthesize cyclic carbonates from CO2 and epoxides. Even in the absence of any co-catalyst and organic solvent, carboxylic-acid-functionalized ILs showed better catalytic activity in the coupling reaction of CO2 and styrene oxide for the production of styrene carbonate than did hydroxyl-functionalized ILs and conventional ILs without any functional moieties. A detailed investigation was carried out on a variety of factors that affected the reactivity, such as the alkyl chain length and the molecular composition of IL molecules including the halide ions. The effect of various reaction parameters such as reaction time, temperature, CO2 pressure and catalyst amount was also investigated in detail. The mechanism underlying the enhanced rate of the cycloaddition reaction in the presence of carboxylic-acid-functionalized ILs was proposed.

The selective catalytic oxidation of hydrogen sulfide to elemental sulfur in a continuous-flow fixed-bed reactor was studied over V2O5-supported Fe-pillared clay (V/Fe-PILC) catalysts. The synthesized catalysts were characterized by X-ray diffraction (XRD), surface area–pore volume measurements, chemical analysis, X-ray photoelectron spectroscopy (XPS), temperature-programmed desorption of ammonia (NH3-TPD), and thermogravimetric (TG) analysis. The reaction tests were conducted at temperatures ranging from 220 to 300 °C. The V/Fe-PILC catalysts exhibited very good catalytic performance toward H2S oxidation at 220–300 °C without much SO2 emission. The H2S conversion over V/Fe-PILC increased with increasing vanadia content up to 7 wt.%. This superior catalytic performance might be related to the uniform dispersion of vanadia species on the Fe-PILC support.

Ionic liquids (ILs) immobilized onto a structurally modified Merrifield peptide resin (MPR) were prepared through the reaction of imidazole with alkoxylated MPR. Elemental analysis and scanning electron microscopy (SEM) observations showed that the immobilized IL groups were effectively incorporated on the support. The MPR-supported ILs (MPR-ILs) proved to be effective heterogeneous catalysts for the synthesis of glycerol carbonate (GC) from glycerol and urea. MPR-ILs with longer alkyl chain linkers and fewer sterically hindered counteranions resulted in higher conversion of glycerol. High temperature, high degree of vacuum and the presence of zinc oxide co-catalyst were favorable for glycerol conversion. The MPR-ILs could be reused in up to three consecutive runs without significant loss of their catalytic activity.

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.

Background Although pedobarographic measurement is increasingly used for clinical and research purposes, relatively few published studies have investigated normative data. This study examined pedobarographic findings in young healthy adults with regard to sex-related differences and correlations among measurement indices. Methods Twenty young healthy adults (mean age, 22.4 years; standard deviation, 1.2 years; and 10 males and 10 females) were included. Weight bearing anteroposterior (AP) and lateral foot radiographs were taken, and dynamic pedobarographic data during treadmill walking and maximum ankle dorsiflexion were obtained. AP talo-first metatarsal angle, naviculocuboid overlap, lateral talo-first metatarsal angle, and plantar soft tissue thickness were measured on foot radiographs. Pedobarographic data including peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel. Results Male and female subjects significantly differed in body mass index (BMI, p < 0.001), AP talo-first metatarsal angle (p = 0.018), soft tissue thickness under the metatarsal head (p = 0.040) and calcaneal tuberosity (p < 0.001), maximum dorsiflexion during stance phase (p = 0.041), peak pressure on the MFF (p = 0.005) and LFF (p = 0.004), and pressure-time integral on the MFF (p = 0.018) and heel (p = 0.001). BMI was significantly correlated with soft tissue thickness under the metatarsal head (r = 0.521, p = 0.018) and calcaneal tuberosity (r = 0.585, p = 0.007), peak pressure on the MFF (r = 0.601, p = 0.005) and LFF (r = 0.487, p = 0.029), pressure-time integral on the heel (r = 0.552, p = 0.012), and total pressure-time integral (r = 0.755, p < 0.001). Maximum dorsiflexion demonstrated significant negative correlations with pressure-time integral on the MFF (r = −0.595, p = 0.007) and total pressure-time integral (r = −0.492, p = 0.032). Pressure-time integral varus/valgus index was significantly correlated with pressuretime integral forefoot/heel index (r = 0.472, p = 0.036). Conclusions Sex-related differences in pedobarographic examination were observed, which could provide useful information in setting appropriate treatment goals and obtaining appropriate control data. The effects of subtalar motion in distributing plantar pressure should be investigated in a future study.

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.

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

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.