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Background: The management of docking site healing in bone transport remains a significant challenge in orthopedic surgery. Traditional assessment methods rely heavily on qualitative radiographic evaluations. This study investigates the utility of pixel value ratio (PVR), an objective quantitative measure, in assessing bone healing at the docking site during bone transport. Methods: This retrospective study included 47 patients who underwent bone transport for lower limb reconstruction between January 2015 and January 2020. Patients were categorized into bone union (n = 35) and nonunion (n = 12) groups based on docking site outcomes. PVR was calculated using two methods (PVR1 and PVR2) at six time points over 24 months post-docking. Subgroup analyses were performed based on gender, age, and surgical site. Results: Of 47 patients, 35 achieved bone union and 12 experienced nonunion. Both PVR1 and PVR2 were consistently lower in the union group compared to the nonunion group at all time points (p < 0.001). In the union group, PVR1 ranged from 1.064 ± 0.050 to 1.108 ± 0.062, while PVR2 ranged from 0.926 ± 0.079 to 0.946 ± 0.062. In the nonunion group, PVR1 ranged from 1.204 ± 0.057 to 1.273 ± 0.020, and PVR2 from 1.039 ± 0.060 to 1.148 ± 0.022. Subgroup analyses revealed that males had significantly lower PVR values compared to females, and tibial cases had lower PVR values compared to femoral cases in both union and nonunion groups (p < 0.05). All juvenile patients achieved union, compared to 71.4% of adults (p < 0.01). Conclusion: PVR demonstrates significant potential as an objective tool for assessing docking site healing in bone transport procedures. The distinct patterns observed between union and nonunion cases provide a foundation for developing clinical guidelines to monitor and predict healing outcomes. Integration of PVR assessment into clinical practice could improve decision-making and optimize treatment protocols in bone transport procedures. [ABSTRACT FROM AUTHOR]

Background: High tibial osteotomy (HTO) is an effective treatment option for deformity correction after fracture. However, performing precise corrective osteotomy for cases with a severe varus deformity and a significant posterior slope poses a significant challenge. Three-dimensional (3D) bone model construction and patient-specific instrumentation (PSI) created from preoperative Computed tomography (CT) may be useful tools in achieving successful outcome for such cases. The present technique describes a hybrid closing-wedge distal tuberosity tibial osteotomy (Hybrid CWDTO) using two PSIs. Methods: Preoperative planning was performed in 3D with reference to the contralateral normal lower extremity CT taken preoperatively, which was then mirrored for analysis. A full-scale bone model and two PSIs were constructed based on this plan to allow for complex correction. During surgery, osteotomy was performed using these sterilized PSIs as guides. Results: Radiographic imaging showed that medial proximal tibial angle (MPTA) improved from 68 to 84 degrees and posterior tibial slope (PTS) improved from 19 to 6 degrees. The standing leg radiograph showed a mechanical varus alignment improvement from 12 to 3 degrees. The 2011 Knee Society Scoring system (2011 KSS) improved from 31 to 95 in objective knee indicators, from 10 to 24 in symptoms, from 14 to 40 in patient satisfaction and from 51 to 95 in activities. Conclusion: Hybrid CWDTO using PSIs is a useful surgical technique for alignment correction post-malunion while also achieving high patient satisfaction. This can assist surgeons in treating complex deformities that are otherwise difficult to treat. [ABSTRACT FROM AUTHOR]

Background: Calcific myonecrosis (CMN) is a rare condition, often considered to be a late sequela of antecedent trauma. Case Report: We describe here our experience in managing a 56-year-old male referred with a painless swelling on the lateral aspect of the left lower leg with a suspicion of a tumour. Results: Clinical and imaging features were classic of CMN. Conclusion: Clinical assessment, role of ultrasound scan in reaching a diagnosis and the management are highlighted. [ABSTRACT FROM AUTHOR]

Background: Assessment of long leg radiographs (LLRs) in pediatric orthopedic patients is an important but time-consuming routine task for clinicians. The goal of this study was to evaluate the performance of artificial intelligence (AI)-based leg angle measurement assistant software (LAMA) in measuring LLRs in pediatric patients, compared to traditional manual measurements. Methods: Eligible patients, aged 11 to 18 years old, referred for LLR between January and March 2022 were included. The study comprised 29 patients (58 legs, 377 measurements). The femur length, tibia length, full leg length (FLL), leg length discrepancy (LLD), hip–knee–ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured automatically using LAMA and compared to manual measurements of a senior pediatric orthopedic surgeon and an advanced practitioner in radiography. Results: Correct landmark placement with AI was achieved in 76% of the cases for LLD measurements, 88% for FLL and femur length, 91% for mLDFA, 97% for HKA, 98% for mMPTA, and 100% for tibia length. Intraclass correlation coefficients (ICCs) indicated moderate to excellent agreement between AI and manual measurements, ranging from 0.73 (95% confidence interval (CI): 0.54 to 0.84) to 1.00 (95%CI: 1.00 to 1.00). Conclusion: In cases of correct landmark placement, AI-based algorithm measurements on LLRs of pediatric patients showed high agreement with manual measurements. [ABSTRACT FROM AUTHOR]

Background: In carefully selected patients with an arthritic valgus knee, distal femoral osteotomy (DFO) can improve symptoms at medium- to long-term follow-up, reducing osteoarthritis progression. To date, there is no clear evidence in the current literature regarding the role of postoperative joint line obliquity (JLO) in valgus deformity correction. Purpose: To assess the clinical and radiological outcomes of medial closing-wedge DFO (MCW-DFO) for the treatment of valgus knees, considering both tibial- and femoral-based deformities, as well as to verify the efficacy and safety of MCW-DFO according to JLO boundaries (≤4°). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis was conducted on a cohort of patients with valgus knees. Patients were divided into 2 groups: femoral-based valgus (FB-V) and tibial-based valgus (TB-V). Knee radiographs were collected before surgery and at the last follow-up. The clinical outcome was evaluated through several validated scores (International Knee Documentation Committee, Knee Society Score, Knee injury and Osteoarthritis Outcome Score, Tegner, Numeric Rating Scale, Crosby-Insall). Results: A total of 30 patients (34 knees) with a mean age of 49.3 ± 9.1 years were included in the study. The overall mean follow-up was 9.4 ± 5.9 years. The mean preoperative hip-knee-ankle angle was 187.6°± 3.3° (range, 181.5°-191°) and the postoperative angle was 180°± 3.1° (range, 176°-185°). Most postoperative JLOs were within the safe zone of ≤4° in both groups (the postoperative JLO was >4° in 4 patients in the TB-V group and 1 patient in the FB-V group), although FB-V knees exhibited significant superior JLO correction (postoperative JLO in the TB-V group: mean, 4.0°± 2.5° [ P =.1]; postoperative JLO in the FB-V group: mean, 2.4°± 1.4° [ P =.5]). Significant improvements in all clinical scores were observed in both groups (P <.01). Additionally, the severity of the osteoarthritis did not worsen at the last follow-up. Conclusion: MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. Both FB-V and TB-V groups showed comparable improvements in the clinical scores, development of osteoarthritis, and the restoration of a neutral mechanical axis. Notably, FB-V knees achieved more JLO correction compared with the TB-V ones. [ABSTRACT FROM AUTHOR]

Rickets results from defective bone mineralization, leading to skeletal deformities. Among those deformities, rickets has been associated with craniosynostosis, the premature closure of cranial sutures. Most of these patients have fusion of major sutures. Rarely, squamosal craniosynostosis in association with rickets has been described. Squamosal craniosynostosis is noted as lacking a definitive head abnormality and difficult visualization on standard imaging modalities, leading to poor recognition. Careful attention should be given to rickets patients to monitor for these unusual suture closures. Additionally, craniosynostosis could be a presenting feature of rickets, and further rickets evaluation of the patient is indicated. [ABSTRACT FROM AUTHOR]

Background: High tibial osteotomy (HTO) aims to realign the varus knee to alleviate stress in the medial compartment. However, detailed information on the impact of HTO on stress distribution across the tibiofemoral joint surface still needs to be completely elucidated. Purpose/Hypothesis: The present study aimed to analyze the subchondral bone density distribution to validate the alignment threshold causing paradoxical changes. We hypothesized that there would be a paradoxical stress change in the medial compartment beyond a specific threshold for lower limb realignment after HTO. Study Design: Case series; Level of evidence, 4. Methods: A retrospective clinical study of 32 knees from 30 patients who underwent medial opening-wedge HTO between 2015 and 2019 was conducted at Hokkaido University Hospital. The subchondral bone density across the tibiofemoral joint was analyzed using computed tomography–osteoabsorptiometry before and after HTO. The high-density area (HDA) within the medial and lateral compartments and their subregions, which were quartered in the coronal plane, was specifically examined. Results: The hip-knee-ankle angle, medial proximal tibial angle (MPTA), joint line obliquity (JLO), and joint line convergence angle significantly changed after HTO (P <.01). The HDA of the medial compartment to the total HDA ratio decreased from 83% to 77%. Paradoxically, the HDA in the most central subregion of the medial compartment increased from 24% to 30%. There were significant differences between MPTA and JLO in patients with and without paradoxical changes in the HDA. MPTA and JLO cutoff values causing paradoxical changes in the HDA were 94° and 4°, respectively. Conclusion: There was a paradoxical stress increase in the M4 region at the medial compartment associated with the MPTA and JLO beyond specific thresholds. Therefore, surgical planning should be cautiously performed to prevent overcorrection, which can lead to adverse stress distribution changes. [ABSTRACT FROM AUTHOR]

Background: Osteochondritis dissecans (OCD) is a condition characterized by abnormal subchondral bone with disturbance of overlying articular cartilage. The role of weightbearing alignment in the pathophysiology of OCD lesion development is not fully understood. Hypothesis: Lower extremity mechanical axis would be concordant with femoral condylar OCD lesion location. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Cases were identified from a single, large academic institutional database using International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Terminology codes associated with OCD. Patients were included if they had a magnetic resonance imaging scan demonstrating the OCD lesion and lower extremity alignment radiographs. OCD lesion location was identified using Cahill and Berg zones. The primary outcome was the association of OCD lesion location with weightbearing mechanical axis. Secondary outcomes included the association of mechanical axis with skeletal maturity, OCD lesion stability, and treatment. For unilateral OCD lesions, mechanical axis was compared between affected and unaffected lower extremities. Results: A total of 86 patients (95 knees) with an OCD lesion of the femoral condyle were identified. The population was 74% male, and the mean age was 21 years. In total, 65% of knees had closed physes, 82% of lesions were unstable, and 85% underwent a surgical procedure. Mechanical axis was located in the same zone as the OCD lesion in 48% of cases and within the same compartment in 56% of cases. Spearman correlation coefficient demonstrated a moderate positive correlation (rs = 0.59). No significant differences were found in the association of mechanical axis and OCD lesion location in subgroup analysis of medial versus lateral femoral condylar OCD lesions, skeletal maturity, stability of the lesion, or treatment group. For patients with varus alignment and medial femoral condylar OCD lesions, the mean lateral distal femoral angle was 89.9°, and medial proximal tibial angle was 85.4°; for valgus alignment and lateral femoral condylar lesions, the lateral distal femoral angle was 84.8°, and medial proximal tibial angle was 88.8°. Patients with unilateral medial femoral condylar OCD lesions were more likely to have varus alignment of the affected extremity compared with the contralateral extremity (59% vs 36%; P =.01). Conclusion: This study demonstrated a relationship between lower extremity mechanical weightbearing axis and femoral condylar OCD location. Patients with unilateral medial femoral condylar OCD lesions frequently had asymmetric varus alignment in the affected extremity. [ABSTRACT FROM AUTHOR]

Background: The proximal tibial epiphyseal inclination can be used as a prognostic factor for good results after knee osteotomy and measured using the tibial bone varus angle (TBVA). This angle depends on the visibility of the epiphyseal plate, which has shown poor reproducibility when measured on standard radiographs by conventional methods. Purpose: To evaluate the measurement reliability of the TBVA and other angles based on the epiphyseal scar using a digital image display. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 100 whole-leg radiographs were analyzed twice by 3 orthopaedic surgeons from 2 countries in a blinded and randomized manner. Observers measured the hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle, and TBVA. The growth plate–tibial plateau (GPTP) angle, defined as the angle between the epiphyseal scar and tibial plateau, was measured; this angle has not yet been described for osteotomy. In addition, a modified version of the TBVA (mTBVA), defined as that between the epiphyseal scar, its center, and the center of the talus, was measured. The Ahlbäck score for osteoarthritis and a 3-grade score for epiphyseal scar visibility were also determined. The reliability of the angle measurements and scoring was evaluated using the Fleiss kappa and intraclass correlation coefficient (ICC). Results: The scores for epiphyseal scar visibility showed fair interobserver (Fleiss kappa correlation coefficient [κ] = 0.29-0.35) and strong intraobserver (Fleiss κ = 0.62-0.69) reliability. TBVA, GPTP angle, and mTBVA measurements showed good interobserver reliability (ICC, 0.76-0.77), while the GPTP angle achieved excellent intraobserver reliability (ICC, >0.9). Conclusion: Using digital image display, angles that depend on the epiphyseal scar—such as TBVA, GPTP angle, and mTBVA—can achieve acceptable measurement reliability despite the low agreement on the visibility of the epiphyseal scar. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to clarify (1) the differences in cortical bone thickness (CBT) of the tibial diaphysis between healthy and osteoarthritic knees and (2) the influences of the femorotibial angle (FTA) and inclination of the medial compartment of the proximal tibia (MCT) on tibial CBT. Methods: The study assessed 60 subjects with varus knee osteoarthritis (OA) (22 males and 38 females; mean age, 74 ± 7 years) and 53 healthy elderly subjects (28 males and 25 females; mean age, 70 ± 6 years). Three-dimensional estimated CBT of the tibial diaphysis was automatically calculated for 2752–11,296 points using high-resolution measurements from CT. The standardized CBT was assessed in 24 regions by combining six heights and four areas. Additionally, the association between the CBT, each FTA, and MCT inclination was investigated. Results: The OA group showed a thicker CBT in the medial areas than in the lateral areas of the proximal tibia, while the healthy group had a thicker lateral CBT. The medial-to-lateral ratio of the proximal tibia was significantly higher in the OA group than in the healthy group. The proximal-medial CBT correlated with FTA and MCT inclinations in the OA group. Conclusions: This study demonstrated that varus osteoarthritic knees showed a different trend of proximal-medial CBT with associations in FTA and MCT inclination from healthy knees, possibly due to medial load concentration. [ABSTRACT FROM AUTHOR]

In the past two decades, the method of endovascular therapy, particularly utilizing covered stents, has been widely employed to treat arteriovenous fistulas (AVF) following traumatic injury. In this report, we present a case study of a patient with post-traumatic femoral arteriovenous fistula treated using a Viabahn endoprosthesis, during which a rare occurrence of stent deployment obstruction was overcome via successful endovascular intervention. Leveraging the unique release line-based deployment mechanism of the Viabahn stent, we were able to adroitly respond to this emergency situation by adopting a suitable approach via minimally invasive endovascular means, and ultimately resolving the impasse. This approach averted the significant trauma associated with open surgical procedures. [ABSTRACT FROM AUTHOR]

Background: For knee osteoarthritis patients, analyzing alignment of lower limbs is essential for therapy, which is currently measured from standing long-leg radiographs of anteroposterior X-ray (LLR) manually. To address the time wasting, poor reproducibility and inconvenience of use caused by existing methods, we present an automated measurement model in portable devices for assessing knee alignment from LLRs. Method: We created a model and trained it with 837 conforming LLRs, and tested it using 204 LLRs without duplicates in a portable device. Both manual and model measurements were conducted independently, then we recorded knee alignment parameters such as Hip knee ankle angle (HKA), Joint line convergence angle (JCLA), Anatomical mechanical angle (AMA), mechanical Lateral distal femoral angle (mLDFA), mechanical Medial proximal tibial angle (mMPTA), and the time required. We evaluated the model's performance compared with manual results in various metrics. Result: In both the validation and test sets, the average mean radial errors were 2.778 and 2.447 (P<0.05). The test results for native knee joints showed that 92.22%, 79.38%, 87.94%, 79.82%, and 80.16% of the joints reached angle deviation<1° for HKA, JCLA, AMA, mLDFA, and mMPTA. Additionally, for joints with prostheses, 90.14%, 93.66%, 86.62%, 83.80%, and 85.92% of the joints reached that. The Chi-square test did not reveal any significant differences between the manual and model measurements in subgroups (P>0.05). Furthermore, the Bland-Altman 95% limits of agreement were less than ± 2° for HKA, JCLA, AMA, and mLDFA, and slightly more than ± 2 degrees for mMPTA. Conclusion: The automatic measurement tool can assess the alignment of lower limbs in portable devices for knee osteoarthritis patients. The results are reliable, reproducible, and time-saving. [ABSTRACT FROM AUTHOR]

Aim: To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods: A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann–Whitney U tests performed. Results: There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5–8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion: Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images. [ABSTRACT FROM AUTHOR]

Background: The coronal plane alignment of the knee (CPAK) classification was first developed using long leg radiographs (LLR) and has since been reported using image-based and imageless robotic total knee arthroplasty (TKA) systems. However, the correspondence between imageless robotics and LLR-derived CPAK parameters has yet to be investigated. This study therefore examined the differences in CPAK parameters determined with LLR and imageless robotic navigation using either generic or optimized cartilage wear assumptions. Methods: Medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) were determined from the intraoperative registration data of 61 imageless robotic TKAs using either a generic 2 mm literature-based wear assumption (Navlit) or an optimized wear assumption (Navopt) found using an error minimization algorithm. MPTA and LDFA were also measured from preoperative LLR by two observers and intraclass correlation coefficients (ICCs) were calculated. MPTA, LDFA, joint line obliquity (JLO), and arithmetic hip-knee-ankle angle (aHKA) were compared between the robotic and the average LLR measurements over the two observers. Results: ICCs between observers for LLR were over 0.95 for MPTA, LDFA, JLO, and aHKA, indicating excellent agreement. Mean CPAK differences were not significant between LLR and Navlit (all differences within 0.6°, P > 0.1) or Navopt (all within 0.1°, P > 0.83). Mean absolute errors (MAE) between LLR and Navlit were: LDFA = 1.4°, MPTA = 2.0°, JLO = 2.1°, and aHKA = 2.7°. Compared to LLR, the generic wear classified 88% and the optimized wear classified 94% of knees within one CPAK group. Bland–Altman comparisons reported good agreement for LLR vs. Navlit and Navopt, with > 95% and > 91.8% of measurements within the limits of agreement across all CPAK parameters, respectively. Conclusions: Imageless robotic navigation data can be used to calculate CPAK parameters for arthritic knees undergoing TKA with good agreement to LLR. Generic wear assumptions determined MPTA and LDFA with MAE within 2° and optimizing wear assumptions showed negligible improvement. [ABSTRACT FROM AUTHOR]

This case study describes the successful management of a patient with primary lymphoedema, who was experiencing lymphorrhoea and epidermolysis, using a multidisciplinary approach. The patient had Klippel–Trenaunay syndrome. The multidisciplinary team, in an outpatient clinic in Japan, included a certified lymphoedema therapist, plastic surgeons, and a wound, ostomy and continence nurse. The team performed complex physical therapy and lymphaticovenular anastomosis, which promoted the resolution of the lymphorrhoea. This resulted in improvements in skin condition, the prevention of recurrent cellulitis, and no increase in limb circumferences during the 1-year follow-up period. This report highlights the importance of a multidisciplinary approach to lymphoedema management, including lymphorrhoea control that fitted in with the patient's daily life. It is hoped that this article will contribute to the improvement of the quality of life of patients with lymphoedema. [ABSTRACT FROM AUTHOR]

Pachydermoperiostosis (PDP), also known as Touraine-Solente-Gole syndrome or primary hypertrophic osteoarthropathy, is a very rare disease mainly characterized by pachyderma, finger clubbing, hyperhidrosis, and periostosis. We reported a case of a patient who suffered from gradual pain and enlargement of both hands and feet for 25 years despite receiving treatment from multiple clinics. He also experienced gradual abnormal changes in his face and scalp. Radiographic images of the lower limbs revealed the presence of subperiosteal bone growth and periosteal hypertrophy. The diagnosis of complete PDP was made late due to its rarity and the unfamiliarity of medical practitioners with the diagnosis. This case highlighted the need for medical practitioners to be aware of rare diseases so that patients may be diagnosed and treated earlier and thereby relieving their anxiety and improve their quality of life. [ABSTRACT FROM AUTHOR]

Hereditary predisposition play an important role in thrombosis, especially in younger patients. Here we studied a young patient who experienced three different episodes of severe thromboses, some of which were life-threatening (pulmonary artery thrombosis, portal and mesenteric vein thrombosis, and arterial thrombosis of the lower leg). Blood levels of clotting related indicators were assessed. We screened 35 genes linked to thrombosis. We discovered a 756 kb duplication that spanned the F9 gene in region q27.1 of the X chromosome. The repeat includes the full F9 gene, thus, the patient had two functional copies of FIX with the FIX activity 192%. An identical repetition was found in the patient's mother. Both the patient and his mother had high, but variable, plasma FIX activities that promote coagulation. The patient's frequent, severe thrombolic events maybe attributed to the duplication of a big portion of the F9 gene and lupus anticoagulant positive. [ABSTRACT FROM AUTHOR]

The authors have diagnosed and treated patients with May-Thurner syndrome who presented with recurrent edema and redness in the left lower leg and foot. Although May--Thurner syndrome is a rare vascular disease, its primary symptoms manifest as edema and redness in the left lower leg and foot, leading the patients to seek foot and ankle surgery. Suspicion should be directed towards May-Thurner syndrome if an obese individual who spends prolonged periods sitting repeatedly complains of edema and redness in the left lower leg and foot area, in which a blood clot forms due to compression of the left common iliac vein within the pelvis. [ABSTRACT FROM AUTHOR]

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Background: Increased posterior tibial slope (PTS) and decreased patellar height (PH) after medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. Hypothesis: No change in PTS or PH would result after MOWHTO with the freehand technique, regardless of the degree of the coronal plane correction. Study Design: Case series. Methods: A total of 62 patients who underwent MOWHTO between 2018 and 2020 were included. Surgery was performed using a dedicated step-by-step protocol to reduce the risk of unintentional slope changes. All patients were evaluated preoperatively and at a 2-year follow-up with the Knee injury and Osteoarthritis Outcome Score and the University of California, Los Angeles physical activity scale. Pre- and postoperative radiographic lower limb alignment parameters—including hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle, proximal posterior tibial angle (PPTA), joint line convergence angle, and joint line obliquity—were measured on full-length lower limb radiographs. PH measurements assessed on lateral and anteroposterior knee radiographs included the Caton-Deschamps, Insall-Salvati, and Schröter indices. Results: A significant change was observed in the coronal plane alignment, with an increase in the MPTA from 84.38° to 90.39° (P <.001) and a consequent increase in the HKA from 172.19° to 180.15° (P <.001). No significant changes were observed in the PTS, as evidenced by a postoperative PPTA of 80.6° versus a preoperative value of 80.4° (P =.2). No significant changes were detected in the mean PH on all 3 indices used—pre- versus postoperative Caton-Deschamps, Insall-Salvati, and Schröter indices measured 0.95 versus 0.93 (P =.2), 1.03 versus 1.03 (P =.5), and 1.56 versus 1.54 (P =.3), respectively. Conclusion: In this study, MOWHTO did not result in significant changes in the PTS or PH when accurate preoperative planning and precise intraoperative freehand technique were adopted.. [ABSTRACT FROM AUTHOR]

Background: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR). Purpose/Hypothesis: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure. Study Design: Case series; Level of evidence, 4. Methods: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded. Results: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively (P <.0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively (P <.001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores (P <.001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was −4.03 ± 0.18 mm and −3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Conclusion: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports. [ABSTRACT FROM AUTHOR]

Nutritional rickets is the failure of normal bone formation in children, caused by vitamin D deficiency, low calcium intake, or a combination of both. In the United States, prolonged breastfeeding without vitamin D supplementation is a major risk factor. Increasing awareness of the rationale for and importance of vitamin D supplements for all breastfed infants and children should reduce the incidence of vitamin D deficiency rickets and prevent bone deformity. [ABSTRACT FROM AUTHOR]

Background: Amputees suffer from symptomatic neuroma and phantom limb pain. Regenerative peripheral nerve interface (RPNI) has recently been regarded as an effective method to prevent neuroma after amputation. However, the verifications of RPNI efficacy are mostly based on subjective evaluation, lacking objective approaches. This study aims to unveil the effect of RPNI on preventing neuroma formation and provide evidence supporting the efficacy of RPNI based on ultrasound. Methods: Amputees of lower limb at Peking University People's Hospital from July 2020 to March 2022 were analyzed retrospectively. The clinical data collected consisted of general information, pathology of primary disease, history of limb-salvage treatment, amputation level of nerve, pain scales such as the Numerical Rating Scale (NRS) and the Manchester Foot Pain and Disability Index (MFPDI). Three months after amputation, the transverse diameter, anteroposterior diameter, and cross-sectional area of neuromas in stump nerves at the end of residual limbs were measured using ultrasound and compared to adjacent normal nerves. Results: Fourteen patients were enrolled in the study, including 7 in the traditional amputation group (TA group) and 7 in the RPNI group. There was no significant difference in basic information and amputation sites between the two groups. The NRS and MFPDI scores of patients in RPNI group were significantly lower than those in TA group, and decreased with the follow-up time increasing, indicating that RPNI could reduce symptomatic neuroma pain. The comparison of preoperative ultrasound and postoperative pathology showed ultrasound could reflect the size of neuroma in vivo. Independent-sample t tests indicated that the ratios of anteroposterior diameter, transverse diameter and area of the cross section of both the neuroma and adjacent normal nerve obtained via ultrasound were significantly reduced in the RPNI group. Conclusion: This study suggested that RPNI can effectively prevent the formation of symptomatic neuroma after amputation using ultrasound. [ABSTRACT FROM AUTHOR]

Background: Pre-operative alignment is important for knee procedures including total knee arthroplasty (TKA), especially when considering alternative alignments. The arithmetic Hip Knee Angle (aHKA) is a measure of coronal alignment calculated using the medial proximal tibial (MPTA) and lateral distal femoral angles (LDFA). Traditionally, aHKA is measured on long leg radiographs (LLR). This study assesses the reproducibility of aHKA measurement on LLR and robotic-assisted TKA planning CT. Methods: Sixty-eight TKA patients with pre-operative LLR and planning CTs were included. Three observers measured the LDFA, MPTA and aHKA three times on each modality and intra-observer and inter-observer reliability was calculated. Statistical analysis was undertaken with Pearson's r and the Bland–Altman test. Results: Mean intra-observer coefficient of repeatability (COR) for LLR vs. CT: MPTA 3.50° vs. 1.73°, LDFA 2.93° vs. 2.00° and aHKA 2.88° vs. 2.57° for CT. Inter-observer COR for LLR vs. CT: MPTA 2.74° vs. 1.28°, LDFA 2.31° vs. 1.92°, aHKA 3.56° vs. 2.00°. Mean intra-observer Pearson's r for MPTA was 0.93 for LLR and 0.94 for CT, LDFA 0.90 for LLR and 0.91 for CT and aHKA 0.92 for LLR and 0.94 for CT. Inter-observer Pearson's r for LLR compared to CT: MPTA 0.93 vs. 0.97, LDFA 0.91 vs. 0.90, aHKA 0.91 and 0.95. Conclusion: When compared to LLR, CT measurements of MPTA, LDFA and aHKA are more reproducible and have a good correlation with LLR measurement. CT overcomes difficulties with positioning, rotation, habitus and contractures when assessing coronal plane alignment and may obviate the need for LLRs. [ABSTRACT FROM AUTHOR]

Background: During opening-wedge, high-tibial osteotomy (OWHTO), various methods of managing the superficial medial collateral ligament (sMCL) can be performed to obtain a sufficient medial side opening. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of distal sMCL release during OWHTO. It was hypothesized that distal sMCL release would not cause valgus instability. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study included 77 patients who underwent OWHTO between January 1, 2018, and October 31, 2019, and completed serial radiological assessments including weightbearing line ratio (WBLR), medial proximal tibial angle (MPTA), coronal translation, total tibial plateau inclination (TTPI), valgus medial joint-space width (valgus-MJSW), valgus joint-line convergence angle (valgus-JLCA), varus lateral joint-space width (varus-LJSW), and varus joint-line convergence angle (varus-JLCA) on standing whole-leg and varus-valgus stress radiographs. Subgroup analysis of pre- to postoperative changes in radiologic parameters was performed according to TTPI (group 1: <25th percentile, group 2: 25th-75th percentile, group 3: >75th percentile) and Ahlbäck osteoarthritis classification (group 1: Ahlbäck grade 1, group 2: Ahlbäck grades 2 and 3). Results: The mean time to final follow-up was 34.6 ± 6.4 months. The WBLR and coronal translation did not change significantly over the follow-up period. The valgus-MJSW at 6 months postoperatively was significantly wider than that preoperatively and at 1 year postoperatively (P <.001). The varus-LJSW at 6 months postoperatively was significantly wider compared with preoperatively and 1 year postoperatively (P <.001), and the varus-LJSW at 1 year postoperatively was wider than that found preoperatively. Coronal translation was significantly more reduced for patients in TTPI group 1 versus group 3 (P =.019). There was no significant differences according to the Ahlbäck groups. All clinical outcomes improved at final follow-up compared with preoperative values (P ≤.002). Conclusion: The study findings indicated that sMCL release did not cause valgus instability or valgus overcorrection at 1 year postoperatively, and improved clinical outcomes were seen at the final follow-up compared with preoperative status after OWHTO with sMCL release. [ABSTRACT FROM AUTHOR]

Patient safety is a paramount concern in the medical field, and advancements in deep learning and Artificial Intelligence (AI) have opened up new possibilities for improving healthcare practices. While AI has shown promise in assisting doctors with early symptom detection from medical images, there is a critical need to prioritize patient safety by enhancing existing processes. To enhance patient safety, this study focuses on improving the medical operation process during X-ray examinations. In this study, we utilize EfficientNet for classifying the 49 categories of pre-X-ray images. To enhance the accuracy even further, we introduce two novel Neural Network architectures. The classification results are then compared with the doctor's order to ensure consistency and minimize discrepancies. To evaluate the effectiveness of the proposed models, a comprehensive dataset comprising 49 different categories and over 12,000 training and testing sheets was collected from Taichung Veterans General Hospital. The research demonstrates a significant improvement in accuracy, surpassing a 4% enhancement compared to previous studies. [ABSTRACT FROM AUTHOR]

To investigate how radiographic techniques and osteoarthritis grade influence measurements of knee joint line obliquity (KJLO) and KJLO-related frontal deformity, and to propose preferable KJLO measurement methods. Forty patients with symptomatic medial knee osteoarthritis indicated for high tibial osteotomy were assessed. Measurements were compared between single-leg and double-leg standing radiographs for KJLO measurement methods including joint line orientation angle by femoral condyles (JLOAF), joint line orientation angle by middle knee joint space (JLOAM), joint line orientation angle by tibial plateau (JLOAT), Mikulicz joint line angle (MJLA) and medial proximal tibial angle (MPTA), as well as KJLO-related frontal deformity parameters including joint line convergence angle (JLCA), knee ankle joint angle (KAJA) and hip-knee-ankle angle (HKA). Influences of bipedal distance in double-leg standing and osteoarthritis grade on the above measurements were analysed. Measurement reliability was evaluated by intraclass correlation coefficient. From single-leg to double-leg standing radiographs MPTA and KAJA did not change significantly, whereas the other measurements showed significant changes: JLOAF, JLOAM and JLOAT decreased 0.88°, 1.24° and 1.77°, MJLA and JLCA decreased 0.63° and 0.85°, and HKA increased 1.11° (p < 0.05). Bipedal distance in double-leg standing radiographs moderately correlated with JLOAF, JLOAM and JLOAT (r p = −0.555, −0.574 and −0.549). Osteoarthritis grade moderately correlated with JLCA in single-leg and double-leg standing radiographs (r s = 0.518 and 0.471). All measurements had at least good reliability. In long-standing radiographs, measurements of JLOAF, JLOAM, JLOAT, MJLA, JLCA and HKA are all influenced by single-leg/double-leg standing; JLOAF, JLOAM and JLOAT are also affected by bipedal distance in double-leg standing; and JLCA is affected by osteoarthritis grade. Knee joint obliquity as assessed by MPTA measurement is independent of single-leg/double-leg standing, bipedal distance or osteoarthritis grade, and has excellent measurement reliability. We therefore propose MPTA as the preferable KJLO measurement method for clinical practice and future research. III, cross-sectional study. [ABSTRACT FROM AUTHOR]

Purpose: An observation was made by the senior author of this paper that patients reported changes in their hip function after a medial opening wedge high tibial osteotomy (MOHTO) for varus pattern osteoarthritis. Alignment changes at the hip after MOHTO have not been previously documented. This study assesses coronal alignment changes at the hip after MOHTO. Methods: We retrospectively analysed pre- and post-operative lower limb alignment radiographs of patients who underwent MOHTO. The medial proximal tibial angle (MPTA) and mechanical axis deviation (MAD) were measured to assess the alignment changes created by the MOHTO. The coronal alignment changes at the hip were evaluated using the mechanical greater trochanter angle (MGTA). Results: 29 osteotomies in 27 patients were included in this study. Results showed MOHTO created alignment changes at the hip. A positive correlation was found between the size of the correction at the knee and the subsequent changes at the hip. The change in the MGTA had a stronger correlation with the MAD than with the change in MPTA (r = 0.684 vs. 0.585). It was found that age, weight, height and BMI had no significant influence on these correlations. Conclusions: Increased correction by the MOHTO lead to increased change in the coronal alignment of the hip. These changes are likely to result in an alteration in the weight bearing portion of the femoral head and the function of the abductors and we recommend assessing the hip joint as part of pre-operative planning. Level of evidence: Prognostic level IV. [ABSTRACT FROM AUTHOR]

Background: Femoral anteversion is a major contributor to functionality of the hip joint and is implicated in many joint pathologies. Accurate determination of component version intraoperatively is a technically challenging process that relies on the visual estimation of the surgeon. The following study aimed to examine whether the walls of the femoral neck can be used as appropriate landmarks to ensure appropriate femoral prosthesis version intraoperatively. Methods: We conducted a retrospective study based on 32 patients (64 hips) admitted to our centre between July and September 2020 who had undergone a CT scan of their lower limbs. Through radiological imaging analysis, the following measurements were performed bilaterally for each patient: anterior wall version, posterior wall version, and mid-neck femoral version. Anterior and posterior wall version were compared and evaluated relative to mid-neck version, which represented the true version value. Results: Mean anterior wall anteversion was 20° (95% CI, 17.6–22.8°) and mean posterior wall anteversion was −12° (95% CI, −15 to −9.7°). The anterior walls of the femoral neck had a constant of −7 and a coefficient of 0.9 (95% CI, −9.8 to −4.2; p < 0.0001; R2 0.77). The posterior walls of the femoral neck had a constant of 20 and a coefficient of 0.7 (95% CI, 17.8–22.5; p < 0.0001; R2 0.60). Conclusions: Surgeons can accurately obtain femoral anteversion by subtracting 7° from the angle taken between the anterior wall and the posterior femoral condyles or by adding 20° to the angle taken between the posterior wall and the posterior femoral condyles. [ABSTRACT FROM AUTHOR]

Venous cystic adventitial disease (VCAD) is a rare vascular anomaly located in the common femoral vein in most cases. We describe the case of a 59-year-old female patient with right leg edema who was misdiagnosed with deep vein thrombosis of the lower extremity at another hospital. Magnetic resonance angiography revealed a round mass in the popliteal vein, with a narrow lumen. Considering the location of the lesion, absence of a history of deep venous thrombosis and trauma, and clinical manifestations, the diagnosis is likely a popliteal vein adventitial cyst. Segmental popliteal vein resection and reconstruction were performed using a cylindrical great saphenous vein graft. No joint connection was found during the operation, and the postoperative pathology confirmed VCAD. [ABSTRACT FROM AUTHOR]

Background: In bifocal varus deformity, double-level osteotomy (DLO) is advocated to treat lower limb alignment to prevent an adverse increase in joint line obliquity. Purpose/Hypothesis: The purpose of this study was to compare the clinical and radiological results after DLO and open-wedge high tibial osteotomy (OWHTO) in patients with combined varus deformity. It was hypothesized that DLO would improve clinical results without increasing the complication rate compared with OWHTO. Study Design: Cohort study; Level of evidence, 3. Methods: Inclusion criteria were medial tibiofemoral compartment pain, varus knee deformity with an abnormal medial proximal tibial angle <84° and a lateral distal femoral angle >90°, a functional anterior cruciate ligament, failure of nonoperative treatment, and a minimum 2-year follow-up with all clinical and radiological data. The rate of return to work or sports; the Knee injury and Osteoarthritis Outcome Score (KOOS); the University of California, Los Angeles (UCLA) activity score; and patient satisfaction were assessed at a minimum of 2 years of follow-up. Statistical comparison of the 2 groups was made using the chi-square or Student t test. Results: A total of 69 consecutive patients were analyzed, of whom 38 underwent OWHTO and 31 underwent DLO surgery. A significant between-group difference was found for all radiological parameters; in particular, there was less joint line obliquity after DLO compared with OWHTO (1.7° vs 5.6°; P <.001). DLO provided better outcomes compared with OWHTO regarding the UCLA score (4.3 vs 6.7; P <.001) and patient satisfaction (2.6 vs 3.9; P <.001), but no significant difference in KOOS or return to work or sports was observed. The OWHTO group had more hinge fractures than the DLO group (34.2% vs 12.9%; P <.001). Conclusion: For combined tibial and femoral varus deformity, DLO produced more physiologic joint line obliquity with slightly improved UCLA and patient satisfaction scores. A greater incidence of hinge fracture was observed after isolated OWHTO compared with DLO due to a larger tibial correction; however, this had little effect on clinical results at the 2-year follow-up. [ABSTRACT FROM AUTHOR]

Background: Malalignments of the lower extremity are common reasons for orthopedic consultation because it may lead to osteoarthritis in adulthood. An accurate and reliable radiological assessment of lower limb alignment in children and adolescents is essential for clinical decision-making on treatment of limb deformities and for regular control after a surgical intervention. Objective: First, does the analysis of full-length standing anteroposterior radiographs show a good intra- and interobserver reliability? Second, which parameter is most susceptible to observer-dependent errors? Third, what is the Standard Error of Measurement (SEM95%) of the absolute femoral and tibial length? Methods: Two observers evaluated digital radiographs of 144 legs from 36 children and adolescents with pathological valgus alignment before a temporary hemiepiphysiodesis and before implant removal. Parameters included Mechanical Femorotibial Angle (MFA), Mechanical Axis Deviation (MAD), mechanical Lateral Distal Femoral Angle (mLDFA), mechanical Medial Proximal Tibial Angle (mMPTA), mechanical Lateral Proximal Femoral Angle (mLPFA), mechanical Lateral Distal Tibial Angle (mLDTA), Joint Line Convergence Angle (JLCA), femur length, tibial length. Intra- and interobserver reliability (ICC2,1), SEM95% and proportional errors were calculated. Results: The intra- and interobserver reliability for almost all measurements was found to be good to excellent (Intra-ICC2,1: 0.849–0.999; Inter-ICC2,1: 0.864–0.996). The SEM95% of both observers was found to be ± 1.39° (MFA), ± 3.31 mm (MAD), ± 1.06° (mLDFA) and ± 1.29° (mMPTA). The proportional error of MAD and MFA is comparable (47.29% vs. 46.33%). The relevant knee joint surface angles show a lower proportional error for mLDFA (42.40%) than for mMPTA (51.60%). JLCA has a proportional error of 138%. Furthermore, the SEM95% for the absolute values of the femoral and tibial length was 4.53 mm for the femur and 3.12 mm for the tibia. Conclusions: In conclusion, a precise malalignment measurement and the knowledge about SEM95% of the respective parameters are crucial for correct surgical or nonsurgical treatment. The susceptibility to error must be considered when interpreting malalignment analysis and must be considered when planning a surgical intervention. The results of the present study elucidate that MAD and MFA are equally susceptible to observer-dependent errors. This study shows good to excellent intra- and interobserver ICCs for all leg alignment parameters and joint surface angles, except for JLCA. Trial registration: This study was registered with DRKS (German Clinical Trials Register) under the number DRKS00015053. Level of evidence: I, Diagnostic Study. [ABSTRACT FROM AUTHOR]

Background and purpose -- Temporary hemiepiphysiodesis by tension-band devices is commonly applied to correct angular limb deformities in children. We aimed to evaluate knee joint morphology after guided growth using these devices. Patients and methods -- In a retrospective multicenter study we analyzed standardized anteroposterior long-leg radiographs of 222 limbs (285 implants) of patients treated by temporary hemiepiphysiodesis with either eight-Plates or FlexTacks for coronal angular deformities of the knee joint between 2013 and 2019. Femoral floor angle (FFA), femoral notch-intercondylar distance (FNID), and tibial roof angle (TRA) were measured pre- and postoperatively to assess the central knee joint morphology. Statistical exploratory analyses were performed using linear mixed models, t-tests, Wilcoxon signed-rank test, and Mann-Whitney U test. Results -- 217 FlexTacks (femur 106, tibia 111) in 104 children and 68 eight-Plates (femur 61, tibia 7) in 35 children were identified. Median time period under growth guidance was 11 months (range 4-42). No statistically significant change in the FFA was detected (eight-Plate: P = 0.2; FlexTack: P = 0.3). A statistically significant difference of the FNID was found in the eight-Plate group (P = 0.02), but not in the FlexTack group (P = 0.3). While TRA increased in both groups, a statistical significance was observed only in the FlexTack group (P < 0.01). Conclusion -- We found minor but clinically irrelevant changes in knee morphology after the treatment. [ABSTRACT FROM AUTHOR]

Background and purpose -- Accurate measuring tools are essential in preoperative planning and for the study of the association between postoperative alignment and clinical outcome in total knee arthroplasty (TKA). We aimed to describe a simple method to measure preoperative hip-knee-femoral shaft (HKFS) angle and postoperative coronal alignment in TKA with the use of standard 3D CT and to compare preoperative HKFS angles and postoperative coronal alignment measured with the 3D CT technique and with standing long-leg hip-knee-ankle (HKA) radiographs. Patients and methods -- HKA radiographs and 3D CT were taken preoperatively and 3 months after the operation in 121 knees. The interrater reliability for the 3D CT method was calculated with intra-class correlation coefficient (ICC). The preoperative HKFS angles and the postoperative deformity measured with the 2 methods were compared and illustrated on Bland-Altman plots, frequency tables, and by Cohen's kappa coefficients (κ). Results -- The 3D CT method was feasible in all knees and the ICC was excellent. Mean (SD, range) difference in HKFS angle measured on HKA radiographs and on 3D CT was -0.3° (0.9°, -4.1° to 2.4°). Mean (SD, range) difference in postoperative deformity was 0.1° (1.6°, -5° to 6°). The 95% limits of agreement were 1.4° and -2° for HKFS and ±3° for postoperative alignment. The agreement in outlier (≥ 3°) identification was moderate with a κ (95% confidence interval) of 0.48 (0.32-0.64). Conclusion -- 3-dimensional computer tomography was feasible and was shown to be more accurate than traditional long-leg radiographs [ABSTRACT FROM AUTHOR]

Context: Radiographic measurements on full-length lower limb views are the standard for lower limb deformity analysis. The published measurements of Paley et al.[1] on lower limb alignment are the gold standard, but were derived from small adult samples. There are no radiographic measurements reported exclusively of South African children. Aims: The study aimed to establish the normal values of lower limb alignment and joint orientation angles in South African children between 5 and 18 years old, at specific age intervals and to compare these measurements to the values as derived from Paley et al.[1] Settings and Design: A cross-sectional radiographic study including all 5--18-year-old children who underwent full-length anteroposterior radiographs between 2012 and 2020 was conducted. Subjects and Methods: Radiographic measurements were done as described by Paley. Differences in measurements obtained and those reported by Paley et al.[1] were compared. Results: A total of 190 patients (110 male; 80 female) with a mean age of 10.0 ± 3.3 years were included. The medial neck-shaft angle (MNSA), mechanical and anatomical lateral distal femoral angle (LDFA) and lateral distal tibia angle (LDTA) remained consistent throughout the age groups. Significant differences between Paley's published values and our cohort were observed for the median mechanical axis deviation (MAD), MNSA and medial proximal tibia angle(MPTA).[1] Conclusion: Significant differences were seen in the mean/median of our MAD, MNSA, and MPTA compared to Paley's work. Other measured values are comparable with previously published adult and pediatric populations. Using the acquired data, we were able to develop set values that could be the norm for pediatric joint orientation angles in the South African population. [ABSTRACT FROM AUTHOR]

Leg length discrepancies are common orthopedic problems with the potential for poor functional outcomes. These are frequently assessed using bilateral leg length radiographs. The objective was to determine whether an artificial intelligence (AI)-based image analysis system can accurately interpret long leg length radiographic images. We built an end-to-end system to analyze leg length radiographs and generate reports like radiologists, which involves measurement of lengths (femur, tibia, entire leg) and angles (mechanical axis and pelvic tilt), describes presence and location of orthopedic hardware, and reports laterality discrepancies. After IRB approval, a dataset of 1,726 extremities (863 images) from consecutive examinations at a tertiary referral center was retrospectively acquired and partitioned into train/validation and test sets. The training set was annotated and used to train a fasterRCNN-ResNet101 object detection convolutional neural network. A second-stage classifier using a EfficientNet-D0 model was trained to recognize the presence or absence of hardware within extracted joint image patches. The system was deployed in a custom web application that generated a preliminary radiology report. Performance of the system was evaluated using a holdout 220 image test set, annotated by 3 musculoskeletal fellowship trained radiologists. At the object detection level, the system demonstrated a recall of 0.98 and precision of 0.96 in detecting anatomic landmarks. Correlation coefficients between radiologist and AI-generated measurements for femur, tibia, and whole-leg lengths were > 0.99, with mean error of < 1%. Correlation coefficients for mechanical axis angle and pelvic tilt were 0.98 and 0.86, respectively, with mean absolute error of < 1°. AI hardware detection demonstrated an accuracy of 99.8%. Automatic quantitative and qualitative analysis of leg length radiographs using deep learning is feasible and holds potential in improving radiologist workflow. [ABSTRACT FROM AUTHOR]

Background: Alignment and rotation of the lower extremities have been suggested to be predisposing pathologic factors for patellar instability. Purpose: To elucidate the relationship between the lower limb alignment and lower extremity rotation in patients with patellar instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 83 patients with patellar instability. Computed tomography scans and standing full-leg radiographs were used to measure the tibial tuberosity–trochlear groove (TT-TG) distance, mechanical femorotibial angle (mFTA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), femoral torsion, and tibial torsion of the different segments. The relationships between femoral torsion, tibial torsion of the different segments, and the mFTA, mLDFA, and mMPTA were evaluated. The levels of tibial torsion and femoral torsion in patients with varus, normal, or valgus alignment were compared with 1-way analysis of variance and chi-square test. Results: The total tibial torsion was significantly associated with total femoral anteversion (r = 0.329; P =.002) and mFTA (r = –0.304; P =.005). There were no significant correlations between mFTA and TT-TG distance or femoral anteversion. Compared with patients with valgus malalignment, patients with varus malalignment tended to have higher tibial torsion. Conclusion: Tibial torsion was associated with leg axis alignment and femoral anteversion in patients with patellar instability. Patients with patellar instability, especially those with concurrent leg axis deformities, should undergo further radiological imaging so that tibial torsion can be assessed and a diagnosis of torsion deformity made early in the treatment pathway and the proper surgical plan formulated. [ABSTRACT FROM AUTHOR]

To evaluate diagnostic usefulness of 3D contrast-enhanced images reconstructed by the maximum intensity projection (MIP) method, it will be compared with Angio DSA and Low Extremity CTA images during the MR Foot Contrast examination. Among the patients who underwent "the MR FOOT with contrast" from September 2020 to October 2022, 40 patients who simultaneously performed Low extremity CTA and Angio DSA were targeted. To evaluate the image, ATA, PTA, and Peripheral artery were classified. Angio DSA and Low Extremity CTA images were compared and analyzed qualitatively based on the MR Foot MIP 3D image. SPSS 26.0 Ver. was used as a statistical program. 3D MR MIP was compared with Angio DSA image to qualitatively analyze anatomical reproducibility. There was no statistical difference between ATA and PTA (p=0.542), whereas Angio DSA image was superior in Peripheral Artery(p<0.05*). Comparing with MR MIP ANGIO and Low Extremity CTA, MR MIP ANGIO images were superior in ATA, PTA, and Peripheral Artery(p<0.01*). The 3D MR MIP ANGIO image was superior compared to the Angio DSA and Low Extremity CTA images for the images below the ankle. Therefore, when evaluating blood vessel below the ankle, it is possible to obtain a blood vessel map with high reproducibility with a small amount of contrast medium compared to Low Extremity CTA and Angio DSA. Thus, MR MIP Angio image could be useful as a supportive image in the treatment planning stage. [ABSTRACT FROM AUTHOR]

Greater levels of bone ultimate fracture load, bone stress--strain index, muscle cross-sectional area, and maximal voluntary isometric plantarflexion (MVIP) strength of the lower leg may be adaptations from chronic exposure to stretch-shortening cycle (SSC) actions. Dancers, a population that habitually performs SSC movements primarily about the ankle joint, may serve as a novel population to gain broader understanding of SSC function. A total of 10 female collegiate dancers and 10 untrained controls underwent peripheral quantitative computed tomography scans of both lower legs and performed MVIPs, countermovement hops, and drop hops at 20, 30, and 40 cm on a custom-made inclined sled. Dancers had greater right and left ultimate fracture load values and significantly (P ≤ .05) greater left leg stress--strain index than controls. Dancers had significantly larger right and left muscle cross-sectional area and MVIP values and hopped significantly higher during all hopping conditions in comparison with controls. Average force--time and power--time curves revealed significantly greater relative force and power measurements during the concentric phase for all hopping conditions in dancers when compared with controls. This investigation provides evidence that dance may be a stimulus for positive muscle and bone adaptations, strength levels, and enhanced SSC capabilities. [ABSTRACT FROM AUTHOR]

Context: Study of muscle volumes in patients after anterior cruciate ligament (ACL) injury and reconstruction (ACL-R) is largely limited to cross-sectional assessment of the thigh musculature, which may inadequately describe posttraumatic and postsurgical muscle function. No studies have prospectively examined the influence of ACL injury and reconstruction on lower-extremity muscle volumes. Objective: Assess magnetic resonance imaging-derived lower-extremity muscle volumes, and quantify quadriceps strength and activation in patients following ACL injury and reconstruction. Design: Prospective case series. Setting: Research laboratory and magnetic resonance imaging facility. Patients (or Other Participants): Four patients (2 men and 2 women; age = 27.4 (7.4) y, height = 169.2 (8.1) cm, and mass = 74.3 (18.5) kg) scheduled for ACL-R. Intervention(s): Thirty-five muscle volumes were obtained from a bilateral lower-extremity magnetic resonance imaging before and after ACL-R. Main Outcome Measures: Muscle volumes expressed relative to (1) a normative database presurgery and postsurgery, (2) limb symmetry presurgery and postsurgery, and (3) percentage change presurgery to postsurgery. Quadriceps function was quantified by normalized knee extension maximal voluntary isometric contraction torque and central activation ratio. Results: Involved vastus lateralis and tibialis anterior were consistently smaller than healthy individuals (z < -1 SD) presurgery and postsurgery in all patients. Involved rectus femoris and vastus lateralis were more than 15% smaller than the contralateral limb presurgery, whereas the involved rectus femoris, gracilis, vastus medialis, vastus intermedius, and vastus lateralis muscle volumes exceeded 20% asymmetry postoperatively. Involved gracilis and semitendinosus atrophied more than 30% from presurgery to postsurgery. Involved maximal voluntary isometric contraction torque and central activation ratio increased by 12.7% and 12.5%, respectively, yet strength remained 33.2% asymmetric postsurgery. Conclusions: Adaptations in lower-extremity muscle volumes are present following ACL injury and reconstruction. Anterior thigh and shank muscles were smaller than healthy individuals, and large asymmetries in quadriceps volumes were observed presurgery and postsurgery. Selective atrophy of the semitendinosus and gracilis occurred following surgery. Volumetric deficits of the quadriceps musculature may exist despite improvements in muscle strength and activation. [ABSTRACT FROM AUTHOR]

Background: The accuracy of distal femoral resection in intramedullary (IM) guided total knee arthroplasty (TKA) depends on femoral morphology and varies according to individual anatomy. This study aimed to characterise coronal plane femoral bowing in Far East Asians according to age, sex, and severity of varus deformity to identify optimal strategies for distal femoral resection in TKA. Method: Femoral anatomical parameters in 656 patients (M/F = 232:424) were assessed using standing long-leg anteroposterior radiography which was fulfilling strict standard. The femur was divided into three longitudinal segments to measure the segmental anatomical axial deviation from the mechanical axis and intersegmental bowing. Coronal plane femoral bowing pattern was categorised based on combined gross bowing and distal bowing. Results: Mean hip–knee–ankle angle; neck–shaft angle; proximal, middle, and distal segmental axial differences; mechanical lateral distal femoral angle; and femur length were 6.7 ± 6.8°, 125.0 ± 5.5°, 5.9 ± 1.7°, 6.1 ± 1.1°, 5.3 ± 1.6°, 88.4 ± 2.6°, and 432.3 ± 23.9 mm in male and 8.4 ± 5.5°, 126.4 ± 5.6°, 5.4 ± 1.5°, 6.6 ± 0.9°, 5.6 ± 1.6°, 89.3 ± 2.6°, and 410.6 ± 23.3 mm in female, respectively. Mean proximal, distal, and gross femoral bowing was 0.3 ± 1.8°, − 0.8 ± 1.8°, and − 0.5 ± 2.9° in male and 1.2 ± 1.6°, − 1.0 ± 1.6°, and 0.2 ± 2.7° in female, respectively. Conclusions: Grossly straight femur with a straight distal part was the most common femoral bowing pattern in Far East Asians. Distal bowing was proved to be a key factor to choose method for distal femoral resection in TKA. Using IM-guide to achieve accurate distal femoral resection in the femora with distal segmental axial deviation between 4–8° and distal bowing less than ± 1° is considered feasible. [ABSTRACT FROM AUTHOR]

Background: X-linked hypophosphatemic rickets (XLH) is the most common cause of inherited rickets. Historically, XLH was treated with oral phosphate and calcitriol (conventional treatment). Burosumab, a fibroblast growth factor 23 (FGF-23) monoclonal antibody, was approved by the United States Food and Drug Administration (FDA) in 2018 for XLH treatment. Nevertheless, conventional treatment of XLH continues to be recommended by some specialists due to lack of published experience with burosumab in the clinical setting. We compared laboratory and radiographic changes observed following transition from conventional therapy to burosumab in pediatric XLH patients as part of routine care. Methods: This retrospective single-center study identified and retroactively studied twelve patients aged 1–18 years old with XLH previously treated with conventional therapy and transitioned to burosumab. Laboratory studies and radiographs were obtained routinely as standard of care during two treatment periods: (1) conventional therapy and (2) burosumab treatment. Laboratory values and radiologic rickets severity scores were compared between periods. Results: All laboratory values demonstrated improvement following 1 month of burosumab treatment, findings which were sustained over the 2-year study period. Rickets severity scores and height z-scores also improved with burosumab. There were no serious adverse events with burosumab, and adverse events overall were very infrequent and mild. One patient developed an asymptomatic mild elevation of serum phosphate while taking burosumab resulting in a temporary pause in therapy. Conclusions: Safety and effectiveness of burosumab in treatment of XLH were demonstrated as burosumab yielded statistically significant improvement in laboratory and radiographic markers of rickets and height compared to conventional therapy. A higher resolution version of the Graphical abstract is available as Supplementary information. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate the reproducibility of planned component positioning including tibial rotational alignment in patient-specific instrumentation (PSI) for total knee arthroplasty (TKA). Methods: A total of 100 knees of 100 patients underwent TKA using PSI (n = 50) or the conventional method (n = 50). Full-length anteroposterior radiographs of the lower limb were taken in the standing position, and the coronal alignments of the femoral and tibial components were measured. Computed tomography (CT) images of the lower limb were obtained preoperatively and postoperatively, and the rotational alignments of the femoral and tibial components were measured. The difference from the preoperative planning in tibial rotational alignment was measured using three-dimensionally merged pre- and postoperative images. The mean values and rates of outliers in each measurement were compared between the PSI group and the conventional group. Results: There were no significant differences in coronal alignment of the femoral and tibial components and rotational alignment of the femoral component between the two groups. With respect to rotational alignment of the tibial component from the preoperatively planned reference axis, the PSI group showed a lower rate of outliers (internal rotation > 10°) than the conventional group (p < 0.05). Conclusions: This study demonstrated that the difference from the preoperative planning in tibial rotational positioning was accurately evaluated using novel three-dimensional measurement method, and PSI could reduce outliers in rotational alignment of the tibial component (internal rotation > 10°). PSI is a useful technique for improving the reproducibility of the planned tibial rotational positioning in TKA. [ABSTRACT FROM AUTHOR]

Background: Tibial torsional malalignment presents a well-known complication of intramedullary nailing for tibial shaft fractures. Purpose: Objective of this study was to investigate the ability to clinically assess tibial torsion differences. Computed Tomography (CT) was used here as the gold standard. Further, intra- and inter-observer reliability of the clinical examination, and radiological measurements were calculated. Methods: Fifty-one patients with torsion-difference CTs, obtained for various reasons, were asked to kneel on an examination couch with free hanging feet. All patients are positioned with 90° flexed knee and neutral ankle. A picture of the lower extremities was obtained from the back of the patient. Two blinded orthopedic surgeons were asked to look at the pictures and measure the tibial torsion with a digital goniometer, based on the axis of the femur in relation to the second ray of the foot. To determine the intra-observer variation, the torsional angles were calculated again after 4 weeks. To be able to compare values, two blinded radiologists calculated torsional differences based on computed tomography. Results: All patients were able to be positioned for clinical assessment (n = 51). Clinical assessment of torsional difference revealed 4.55° ± 6.85 for the first, respectively, 4.55° ± 7.41 for the second investigator. The second measurement of the first investigator revealed a value of 4.57° ± 6.9. There was a good intra-observer agreement for clinical assessment (ICC 0.993, p < 0.001). Also, the inter-observer agreement showed a good inter-observer agreement (ICC 0.949, p < 0.001). Evaluation of radiological inter-observer assessment could also show a good inter-observer agreement (ICC 0.922, p < 0.001). The clinical method showed a good correlation to the CT method (0.839, p < 0.001). Additionally, the Bland–Altman plot was used to compare graphically both measurement techniques, which proved the agreement. Conclusion: In summary, computed tomography-assisted measurement of tibial torsion and clinical assessment correlated significantly good. In addition to that, clinical measurement has a good intra- and inter-observer reliability. Clinical examination is a reliable and cost-effective tool to detect mal-torsion and should be part of the repertoire of every surgeon. [ABSTRACT FROM AUTHOR]

Introduction: Patient-specific instruments (PSI) have been shown to be a good solution in getting accurate bone cuts in total knee arthroplasty (TKA) in many studies. However, the need for an extra CT/MRI makes the existing PSI method costly and unsafe. X-ray-based PSI can solve these problems, if proven to be accurate. The purpose of this study was to introduce a novel method to measure the performance of X-ray to 3D-based PSI (X3DPSI®) in achieving planned bone cuts by comparing with conventional instruments (CI). Materials and Methods: This was a prospective study of a total of ten patients undergoing TKA surgery. Preoperative full length lower limb scanogram was done with specialized calibration strap-on marker to develop X3DPSI® which was used intraoperatively for the placement of guiding pins for the cutting jig. Similarly, intraoperative guide pins were placed using CI also. Calibrated intraoperative X-ray images, in AP and LAT view, were taken while the cutting-block guiding pins were placed on the distal femur and proximal tibia. These X-ray images were used to calculate the cutting plane alignments for femur and tibia and to simulate the postoperative hip–knee–ankle (HKA) angle and MAD (mechanical axis deviation), in a virtual Tabplan3D environment for both the methods. Results: The results showed that there was a significant difference between the two methods in terms of femoral cutting plane angles and in terms of the HKA angles and MAD. There was no significant difference in the tibial cutting plane angles in the coronal plane. Conclusion: The mechanical axis alignment achieved based on the virtual cuts made using the X3DPSI® was significantly better than the alignment achieved based on the cuts made using the CI, in terms of both HKA and MAD. This novel method of X-ray-based PSI is a low-cost alternative to CT/MRI-based PSI if found to be accurate in future planned studies. [ABSTRACT FROM AUTHOR]

Childhood hypophosphatasia (HPP) presents with bowing of the limbs, poor mobility, chronic pain, short stature, fractures, and motor impairment. Enzyme replacement therapy (ERT) provides improved pulmonary and physical function in life-threatening perinatal and infantile forms of HPP. However, treatment of those patients without life-threatening HPP is limited. This report describes the results of asfotase alfa (Strensiq®, Alexion Pharmaceuticals, Inc.) treatment in a 6-year-old girl with childhood HPP, who presented with premature loss of primary teeth, low mobility, and chronic pain in the legs. Sequence analysis of the TNSALP gene revealed three heterozygous variants; c.526G>A (reported previously), c.1051G>C (novel), c.787T>C (reported previously). After a four-year follow-up under ERT, a marked reduction in leg pain and restlessness was observed and physical therapy assessments showed remarkable improvements in motor function, pain score, and quality of life. The treatment decision in childhood HPP is not as clear as in infantile and perinatal forms and it is mostly based on the clinical and radiological condition of the patient. In patients with childhood HPP without severe skeletal involvement but accompanying motor retardation, ERT may improve quality of life, motor functions, and daily activities. [ABSTRACT FROM AUTHOR]

Objectives To explore the efficacy of plasma exchange (PE) therapy in refractory idiopathic inflammatory myopathy (IIM) patients with positive anti-signal recognition particle (SRP) antibody. Methods Nine refractory IIM patients with positive anti-SRP antibody were enrolled, who received PE therapy at Ruijin Hospital from October 2017 to December 2020. The clinical manifestations, laboratory tests, chest CT and lower extremity MRI images before and after PE therapy were compared. The treatment response was evaluated by the 2016 ACR/EULAR myositis response criteria. Results A total of 88.9% (8/9) of subjects had achieved improvement by 3 weeks after PE therapy, with 55.6% (5/9) minimal improvement and 33.3% (3/9) moderate improvement. There were statistically significant improvements between baseline and after PE therapy at 3 weeks on the core set measures: physician global activity, patient global activity, HAQ, manual muscle testing (MMT), extramuscular disease activity, and muscle enzymes activity including creatine kinase (CK), lactate dehydrogenase (LDH), aspartate transaminase (AST), except for alanine transaminase (ALT). Moreover, the chest CT showed regression of ground glass opacities and irregular linear opacities after PE therapy in four patients with interstitial lung disease. The MRI images of lower extremity in four patients showed reduction of muscle oedema after the therapy. Conclusion PE therapy is effective for refractory IIM patients with positive anti-SRP antibody. It should be considered as an alternative treatment for those patients who are resistant to the combined therapy of glucocorticoids and immunosuppressive agents. [ABSTRACT FROM AUTHOR]

Summary: Atypical femoral fractures (AFFs) are categorized as low-energy fractures of the femoral shaft or subtrochanteric region. The use of computed tomography-based finite element analysis demonstrated that the femoral weakest point against tensile stress coincided with AFF location, which was determined by the lower limb axis and femoral bowing. Introduction : This study aimed to assess the relationship between the femoral weakest point against tensile stress and the lower limb axis and geometry, including femoral bowing, using a computed tomography (CT)-based finite element analysis (FEA) model. Methods: We retrospectively reviewed 19 patients with AFFs and analyzed their CT images of the contralateral intact femur. We performed FEA to find the maximum principal stress (MPS) and maximal tensile stress loading area (femoral weakest point, FWP) of each patient and matched the FWP with the real location of AFF. We applied mechanical axes differently, as neutral, varus, and valgus, in the FEA model, when we analyzed the change in MPS and FWP based on lower limb alignment. We compared the degree of agreement between the real fracture location and FWP before and after knee mechanical axis adjustment. Results: The average participant age was 75.9 (range, 61–87) years, and all participants were women. In the 19 patients included, we observed 20 and 7 shaft and subtrochanteric AFFs, respectively. The average mechanical axis at the knee joint level was 22.6 mm (range, 0–70 mm) of the varus. All the patients showed an increasing trend of MPS and a distal movement of FWP when the mechanical axis of the knee was applied from the valgus to varus alignment. The root mean square errors between the FWP and real fracture location were 14.58% and 10.87% before and after adjustment, respectively, implying that the degree of agreement was better in patients who underwent mechanical adjustment. Conclusion: The use of CT/FEA demonstrated that the FWP against tensile stress coincided with AFF location, which was determined by the lower limb axis and femoral bowing. [ABSTRACT FROM AUTHOR]