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To more accurately interpret the anterior humeral and radiocapitellar lines on simple radiographs of pediatric elbow, we investigated age-related changes of the capitellar ossific nucleus (CON) by using MRIs. Elbow MRIs from 79 children aged 1-16 years and free from demonstrable lesions in the distal humerus were retrospectively reviewed. On coronal images, the distal cartilaginous vertex of the capitellum, which articulates with the center of the radial head, was situated about 15%p laterally from the center of CON regardless of age. On sagittal images, the anterior humeral line passed the center of CON in older children (>6 years), but passed anteriorly in children with an age ≤6 years. Also on sagittal images, the anterior cartilaginous vertex of the capitellum was positioned within 10% of the level of the center of CON in all age groups. Recognition of the capitellar ossification pattern within the lateral condyle would aid in more accurate assessment of pediatric elbows on simple radiographs. Based on the results of the present MRI study, the following points were identified for the interpretation of simple radiographs: (1) The radiocapitellar line on anteroposterior views intersects the CON by about 15%p laterally regardless of age; (2) The anterior humeral line on lateral views intersects the center of the CON in older children, but passes anteriorly in younger (≤6 years) children; and (3) The radiocapitellar line on lateral radiographs invariably passes the center of CON regardless of the age.

OBJECTIVES This study aimed to investigate the clinico-radiological factors of related future surgical treatment in patients with pediatric flexible flatfoot (FFF) who first visited the orthopedic clinic before the age of 10 years. METHODS Sixty-five patients diagnosed with moderate/severe idiopathic FFF deformity between the ages of 2-10 years were included. We developed prognostic models for the risk of the surgery during the follow-up period. RESULTS Twenty (30.8%) patients required surgical treatment, and all of them underwent calcaneal lengthening osteotomy. Among them, 7 (10.8%) patients required concomitant Achilles-lengthening surgery. Unilateral involvement, older age, smaller calcaneal pitch angle, and higher talo-first metatarsal malalignment were considered high-risk factors for pediatric FFF surgery. Prognostic models identified three prognostic risk groups based on those factors, and survival curves revealed significant differences among the groups. CONCLUSIONS Our prognostic models help predict the failure risk of conservative management of pediatric idiopathic FFF. LEVEL OF EVIDENCE Level III, prognostic study.

Background In the Korean medical system, the severity classification for a specific disease depends primarily on its nationwide admission rate in tertiary hospitals. Inversely, one of the important designation criteria for a tertiary hospital is the hospital's treatment ratio of patients classified as having a specific severe disease. Most diseases requiring pediatric orthopaedic surgery (POS) are not currently classified as high severity in terms of disease severity. We investigated the admission rates for the representative POS diseases in tertiary hospitals and compared these rates with those for adult orthopaedic surgery (AOS) diseases. Methods Seven POS diagnoses and three AOS diagnoses were selected based on frequency of admission. Nationwide sample data were used to investigate the admission rates for these representative diagnoses from 2008 to 2017. Results Six of the seven frequent POS diagnoses presented high admission rates in tertiary hospitals (62.5–92.3%). In contrast, all frequent AOS diagnoses presented low admission rates in tertiary hospitals. Conclusion The admission rates of frequent POS diagnoses in tertiary hospitals are high. Considering that these rates are the most important factors for the classification of disease severity, POS diseases seem to be underestimated in terms of severity. This may lead to a tendency for tertiary hospitals to intentionally reduce the admission of children with POS diseases. As a result, these children may not receive appropriate professional care. Therefore, for the disease severity, POS diseases should be classified differently from general AOS diseases by using different criteria reflecting the patient's age., Graphical Abstract

Background This study aimed to investigate the presence of physeal abnormality and its effect on growth in children with high-risk neuroblastoma treated by intensive multimodal treatment with/without 13-cis-retinoic acid (13-CRA). Methods Fifteen patients diagnosed with high-risk neuroblastomas at the age of 1 to 10 years, who received treatment such as high-dose chemotherapy and autologous stem cell transplantation with/without 13-CRA, and with complete data during their >2-year follow-up were retrospectively reviewed. The physeal abnormalities were investigated by whole-body magnetic resonance imaging, serially performed every 3 to 6 months. The patients' height growth was also investigated and compared with that of age-and-sex-matched patients with brain tumors who also underwent high-dose chemotherapy and autologous stem cell transplantation. Results Six of 15 patients presented multifocal physeal abnormalities during follow-up, and all lesions occurred in patients with 13-CRA use. The lesions in 3 patients completely resolved spontaneously without any adverse effect on growth, but some lesions in the other 3 patients progressed to disturb the bony growth. Height growth of matched patients with brain tumors were not significantly different, and none of the matched controls showed definite bony deformity during the follow-up. Conclusions Some children who were treated for high-risk neuroblastomas experienced multifocal physeal insults, probably due to the use of 13-CRA. Most lesions resolved spontaneously, but some led to bony deformity. If the lesions are not followed by premature physeal closure, there seems to be no further adverse effect of 13-CRA on leg length growth. Routine periodic screening for physeal status is needed for the patients with high-risk neuroblastomas using 13-CRA. Level of evidence Level IV-prognostic study.

Purpose This study investigated the initial angular deformity of proximal tibial metaphyseal fracture in children and its recovery during follow-up according to the cause of injury. Methods Prospective data about the patients with a proximal tibial metaphyseal fracture at the age less than six years and available follow-up data at two years post-trauma were retrospectively reviewed. They were grouped into trampoline-related injuries (TRI) and non-TRI groups based on the cause of injury. Proximal tibial valgus and recurvatum angles were measured to assess angular deformity on the coronal and sagittal planes, respectively. Results A total of 47 patients (33 TRI and 14 non-TRI) were included. Initially, the valgus angles were -1.5° in TRI and 1.6° in non-TRI groups (p < 0.001) and the recurvatum angles were 7.8° in TRI and 4.1° in non-TRI groups (p = 0.048). After two-year follow-up, the valgus angles were 0.2° in TRI and 0.9° in non-TRI groups (p = 0.070), and the recurvatum angles were 6.5° in TRI and 2.3° in non-TRI groups (p = 0.001). Conclusion For children with a proximal tibial metaphyseal fracture, the initial coronal deformity was different according to the injury cause (varus in TRI whereas valgus in non-TRI). Although there was a near complete recovery after approximately two years of follow-up in the coronal deformities, the sagittal deformity (genu recurvatum) seems to recover incompletely or tardily, especially for those caused by TRI. Level of Evidence III

BACKGROUND The discoid lateral meniscus (DLM) in children often presents peripheral rim instability (PRI) and is susceptible to tear or subluxation, which manifests symptoms and leads to a poor prognosis. We aimed to investigate the association between preoperative clinical and MRI findings and the intraoperative findings of PRI. METHODS Children and adolescents aged younger than 16 years who underwent surgical treatment for DLM were retrospectively reviewed. Cases of bucket-handle tear were not included because they would confound the stability of the peripheral rim. Total 60 knees from 47 children were included. PRI was additionally subdivided based on the location, such as anterior, middle, and posterior, during the investigation. RESULTS In multivariate analyses, both central (inward) (P=0.004) and external (outward) (P=0.029) displacement of lateral meniscal margin, and peripheral tear of the anterior body (P=0.022) were significant predictors of PRI, regardless of the location. The predictive factors for PRI based on each location were female gender (P=0.004), subjective symptom of clicking sound (P=0.023), and central displacement of the anterior meniscal margin (P=0.034) for anterior PRI; flexion contracture >10 degrees (P=0.017) and peripheral tear of the middle body (P

Background: The presence of asymmetric skin folds in the medial thigh (ASM) is often used as one of the screening items for developmental dysplasia of the hip (DDH). However, few studies have evaluated the clinical relevance of ASM in DDH. Methods: We reviewed the data of 584 infants aged 4–12 months who were referred to our institute because of suspicious findings in periodic infantile DDH screenings. The reasons for referral were classified into ASM, gluteal asymmetry, limb-length discrepancy, limitation of hip abduction, and click/clunk of the hip. A simple radiograph and hip examination including stability assessment were evaluated in all the infants by an experienced pediatric orthopedic surgeon. Results: Most of the referred infants presented with ASM only (78.4%, 458/584), but none of them were diagnosed with DDH. On the other hand, about 18.3% of infants referred for other reason(s) were diagnosed with DDH. Conclusion: Although the presence of ASM was the most common reason for referral, it had little clinical significance as a screening item for DDH in the infants aged 4–12 months. Therefore, ASM alone is not a clinical indicator of DDH. Key Words: congenital, diagnosis, hip dislocation, infant, thigh

Background The middle phalangeal type of postaxial polysyndactyly (MPPP) of the foot is a common congenital limb anomaly and is usually treated surgically at a young age. Owing to the insufficiency of radiologic evaluation due to largely cartilaginous portions of the pediatric foot, we performed intraoperative arthrography (IOA) for MPPP. This study was aimed at presenting a new classification system for foot MPPP in young children based on IOA findings and investigating its intraoperative decision-making. Methods Thirty-seven patients aged below 2 years who underwent IOA and surgical treatment of foot MPPP in our institute between January 2018 and April 2020 were retrospectively reviewed. The mean patient age at operation was 1.31 years (range, 0.91 to 1.99 y). IOA was performed in the common proximal interphalangeal (PIP) joint. The excisional level and side were determined on the basis of the IOA findings and bony alignment between the proximal and distal phalanges for functional and cosmetic purposes. Arthrographic findings and surgical procedures were recorded. Results A new classification divided MPPP into 2 major types according to the presence (type A) or absence (type B) of longitudinal contrast filling between the fifth and sixth middle phalanges. These 2 major types were further divided into 4 subtypes according to the shape of the PIP joint by contrast filling. There were 19, 15, and 3 cases of type A, B, and indeterminate IOA. Fifth and sixth ray excisions were performed in 26 and 11 cases, respectively. Interobserver reliability of the classification represented excellent agreement (Cohen κ coefficient=0.823). Conclusions Our new classification based on IOA helped determine the articular dominance and its detailed morphology, which can help predict postoperative stability and mobility of the remaining toe. IOA is a simple, safe, and useful imaging tool for the surgical treatment of foot MPPP in patients aged below 2 years. Level of evidence Level III.

We investigated the differential MRI findings in children with transient synovitis of the hip in whom septic arthritis was suspected. Under the hypothesis that disease progression can alter representative MRI findings, we stratified these findings in accordance with symptom duration as this can correlate with disease progression. We analyzed 65 children who underwent MRI for acute hip pain and who were suspected of having a septic condition (i.e. presented with fever or increased inflammatory markers) when the imaging was performed. Symptom duration was defined as the interval from the first presentation of hip pain to the MRI scan. We divided the patients into two subgroups according to symptom duration: patients with short symptom duration (≤2 days, short-term subgroup, n = 30) and those with long symptom duration (≥3 days, long-term subgroup, n = 35). Twenty-eight (43.1%) of the study subjects were diagnosed with septic arthritis. Whereas only a high-grade joint effusion was a significant MRI finding differentiating septic arthritis from transient synovitis in the whole cohort, the presence of contralateral joint effusion in the short-term subgroup (P = 0.024) and the absence of a change/enhancement of the signal intensity of soft tissue in the long-term subgroup (P < 0.001) were significant predictors of transient synovitis. The significances of differential MRI findings for septic arthritis and transient synovitis seem to change according to symptom duration. We suggest that symptom duration, which may correlate with disease progression, should also be considered when interpreting MRIs of children under suspicion of septic arthritis.

OBJECTIVES The objective of this study was to investigate the predictive value of asymmetric joint space widening on simple radiographs for the presence of hip joint effusion in children with unilateral hip pain. METHODS Sixty-eight patients aged 6 to 17 years with both simple radiograph and magnetic resonance imaging of both hips were retrospectively reviewed. We evaluated the predictive effects of radiographic surrogates for joint space widening on the presence of high-grade hip joint effusion. We also sought to investigate a predictive model for the presence of hip joint effusion with the patients' clinical and radiological data. RESULTS Radiographic values showed high specificity but low sensitivity for the presence of high-grade joint effusion. On multivariate analysis, sex and the difference ratio of medial and superior gaps were independent predictive factors for unilateral high-grade hip joint effusion. CONCLUSIONS For children 6 years and older with asymmetric hip joint space widening on simple radiographs, further evaluations for the presence of hip joint effusion should be considered because of its high specificity. The predictability can improve if both medial and superior gaps, and sex are included in the evaluation. In girls, hip joint effusion seems to widen the joint space more easily than in boys, which may be owing to the more ligamentous laxity of and less musculature around the hip in girls. However, the risk of joint effusion should not be underestimated even if a child presents symmetry on the simple radiograph because of its low sensitivity and the possibility of bilateral involvements or early stage of diseases.

Backgroud Many studies have reported injury characteristics of individual traumatic situations. However, a comparative analysis of specific risks is meaningful to better understand injury characteristics and help establish injury-prevention measures. This study was conducted to investigate and compare injury characteristics in children and adolescents by various outdoor traumatic situations. Methods Outdoor traumatic situations were determined and classified into physical activity-related injury (n = 3,983) and pedestrian (n = 784) and passenger (n = 1,757) injuries in traffic accidents. Home injury (n = 16,121) was used as the control group. Then, the characteristics of each outdoor trauma were compared with 1:1 matched indoor trauma (among home injuries); each outdoor traumatic situation's predisposing risk for the injured body part, injury type, and injury severity were analyzed; and changes by age of frequency ranking among physical activity-related injuries were investigated. Results Outdoor trauma showed higher risks for limb injuries (injured body part), fracture and muscle/tendon injuries (injury type), and severe injuries (severity) than indoor trauma. Various outdoor traumatic situations presented different predisposing effects on injury characteristics. Among physical activity-related injuries, bicycle injury was commonest across all ages, and playing activities were common causes for injury for individuals of age < 9 years, whereas sports activities overwhelmed the common causes thereafter. Conclusions The findings would help to better understand the specific injury risk of various outdoor traumatic situations and may potentially facilitate the establishment of more effective injury-prevention measures.

Background Since 2015, we have performed arthroscopy-assisted closed reduction and percutaneous pinning (A/S-CRPP) for children with a displaced lateral condylar humeral fracture (LCF). The purpose of this study is to introduce our A/S-CRPP method and present its outcomes. Methods In total, 39 displaced (>2 mm) LCFs for which A/S-CRPP was initially attempted and with available follow-up data of >12 months were retrospectively reviewed. A/S-CRPP is performed in the following order: closed reduction, 1 provisional K-wire fixation, arthroscopic verification of the reduction status, rereduction if needed, and additional fixation. Our reduction technique using articulations of the ulnohumeral and radiohumeral joints and direct compression is introduced. For rereduction, modified reduction forces were applied based on the arthroscopic findings. To evaluate the learning curve effect, the initial 6 months after the first case of A/S-CRPP was regarded as the "initial period." There were 12 cases during this period. Results Among the 39 cases, surgical method was intraoperatively converted to open reduction and percutaneous pinning in 9 and A/S-CRPP was completed in 30. Among the 9 open reduction and percutaneous pinning conversion cases, 7 conversions occurred in the initial period. Among the 30 patients who underwent A/S-CRPP alone, 10 needed rereduction after an arthroscopic examination. No patients presented with >10-degree angular deformity or elbow motion limited >20 degrees, compared with the contralateral elbow. Postoperative radial nerve palsy occurred in 2 patients, all in the initial period. Both were resolved within 5 months, postoperatively. Conclusions We suggested our A/S-CRPP surgical technique for displaced pediatric LCF. It may require a 6-month learning curve period. Although more studies are needed, it seems to be a safe and appropriate surgical technique for treatment. Level of evidence Level IV-therapeutic study.

Objectives To investigate the fracture pattern and periosteal entrapment in adolescent distal tibial physeal fractures. Design Retrospective case series. Setting Level I academic trauma center. Patients/participants Fifty patients (10-16 years of age) with displaced Salter-Harris type II, III, or IV distal tibial physeal fractures were retrospectively reviewed. Intervention Periosteal involvement, fracture pattern. Main outcome measurements We investigated the incidence and location of periosteal entrapment in those fractures and the angle of the fracture plane of metaphyseal fragments on axial plane by using magnetic resonance imaging. Results Of the 15 type II, 12 type III (4 malleolar and 8 Tillaux), and 23 type IV (2 malleolar and 21 triplane) fractures, 72.0% (36/50) presented with periosteal entrapment. Among all type II and triplane fractures, periosteal entrapment was observed in the anterolateral corner when there was any displacement on that corner. By contrast, only 1 of 8 Tillaux fractures presented with periosteal entrapment. In almost all supinated foot injuries of type II and triplane fractures, the metaphyseal fracture line was parallel to the intermalleolar axis on axial plane. Conclusions Salter-Harris type II and triplane fractures have a high risk of periosteal entrapment especially in the anterolateral corner. Therefore, even without preoperative magnetic resonance imaging, surgical repositioning of entrapped periosteum should be considered after failed closed reduction. In cases of supinated foot injuries of type II or triplane fractures requiring surgical fixation, a metaphyseal fracture plane parallel to the oblique coronal plane connecting the medial and lateral malleoli may assist surgeons in achieving appropriate metaphyseal fixation. Level of evidence Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BackgroundMany case studies have been published about trampoline-related injury (TRI); however, a comparative study could allow a more specific analysis of the characteristics of TRI, and enable more differentiated approaches to prevent such injuries. We investigated the injury mechanism of TRI in children compared with other pediatric trauma.MethodsOf 35,653 children (age 0-18 years) who visited the pediatric emergency department after traumatic injuries from January 2011 to June 2017, 372 patients with TRI (TRI group) were retrospectively identified. Among the remaining 35,281 patients with other trauma (non-TRI group), 372 were 1:1 matched to the TRI group according to sex, age, injured body part, and body weight (matched-control group). The patients' data, injured site, and injury patterns were compared between the groups.ResultsThe most frequently injured body part was the knee/lower leg in the TRI group and the head in the non-TRI group. The most frequent injury types were fractures in the TRI group and open wounds in the non-TRI group. In the comparison between the TRI and matched-control groups, the most common lower-extremity fractures were proximal tibial fractures with varus angulation in the TRI group and tibial shaft spiral fractures in the matched-control group. For the upper extremities, the risk of lateral condylar humeral fracture was higher in the TRI group. The TRI group presented more physeal involvements.ConclusionsThe risks of varus stress injury (proximal tibial fracture with varus angulation in lower extremity and lateral condylar humeral fracture in upper extremity) were higher in the TRI group than in matched-control group. Thus, varus shearing force seems to be an important injury mechanism in TRI in addition to compressive force. This varus force may increase the risk of physeal injury by generating additional shear force on the physis.

OBJECTIVES Under the hypothesis that the elbow alignment, namely the carrying angle, could predispose individuals to a specific type of pediatric elbow fracture after a fall onto an outstretched arm, we investigated the relationship between radiographic carrying angle and elbow fracture type in children. DESIGN Retrospective case-control study. SETTING Level I pediatric trauma center. PATIENTS/PARTICIPANTS We reviewed 374 children who were diagnosed with supracondylar fracture (SCF, n = 208), lateral condylar fracture (LCF, n = 132), and radial neck fracture (RNF, n = 34). INTERVENTION The association between the radiographic carrying angle and the fracture type was investigated. MAIN OUTCOME MEASUREMENTS To adjust for bias, 2 statistical methods were used: multivariate analysis using a baseline-category logistic model and a case-matching method using propensity score analysis. RESULTS In the multivariate analysis, with SCF patients set as the baseline category, a more valgus-deviated elbow (increased carrying angle, P = 0.011) predisposed individuals to RNF, whereas a more varus-deviated elbow (decreased carrying angle, P < 0.001) predisposed them to LCF. In the case-matched analysis, there were also significant differences in carrying angles between RNF and case-matched SCF patients (14.3 vs. 11.4 degrees, P = 0.013) and between LCF and case-matched SCF patients (7.7 vs. 11.7 degrees, P < 0.001). CONCLUSIONS Elbow alignment, which may influence the transmission of traumatic force during a fall onto an outstretched elbow, could be a predisposing factor for specific types of pediatric elbow fracture. The results provide the additional information about the injury mechanisms of pediatric elbow fracture and may deepen our understanding of the fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To evaluate the clinical and prognostic impact of musculoskeletal manifestations as the only initial presenting symptom in childhood acute lymphoblastic leukemia (ALL). Study design We retrospectively reviewed 158 children with precursor B-cell type ALL who were followed up for >2 years. The patients were assigned to the groups musculoskeletal manifestations (n = 24) or nonmusculoskeletal manifestations (n = 134) based on initial presenting symptom. The symptom duration (regarding any initial presenting symptom) and the leukemic symptom duration (regarding symptoms of systemic manifestation, such as fever, bleeding, or pallor) were assessed, along with other clinical characteristics. Results The musculoskeletal manifestations group exhibited a longer symptom duration than the nonmusculoskeletal manifestations group (43 days vs 22 days, P = .006), but overall survival did not significantly differ between the groups. Multivariate analysis indicated that a longer symptom duration did not affect prognosis but that a longer leukemic symptom duration was associated with a poorer prognosis (hazard ratio, 7.720; P = .048). Conclusion Musculoskeletal manifestations are associated significantly with diagnostic delay, but this delay does not affect the prognosis. Diagnostic delay after the onset of leukemic symptoms, however, does appear to affect the prognosis. Intensive evaluations for hematologic malignancies may be unnecessary in children who complain of limb pain without any definite cause, unless they also present with accompanying leukemic symptoms.

Background Treatment for septic arthritis of the sternoclavicular (SC) joint with concomitant osteomyelitis of the clavicle often requires joint resection rather than simple incision and drainage. We evaluated the effectiveness of resection arthroplasty for patients with septic arthritis of the SC joint. Methods We retrospectively reviewed 10 patients who underwent resection arthroplasty for SC joint septic arthritis between 1996 and 2008. The mean patient age was 52.8 ± 10.5 years (range, 40-72 years), the mean symptom duration before surgery was 16.9 days (range, 2-60 days), and the mean follow-up period was 35.4 ± 42.2 months (range, 10-108 months). Diagnoses were based on physical examination, laboratory tests, and radiologic studies including magnetic resonance imaging. Each patient had concomitant osteomyelitis of the clavicle. In addition, 4 patients had mediastinitis and 1 had osteomyelitis of the adjacent ribs. All patients underwent SC joint resection and intramedullary ligament reconstruction, followed by intravenous antibiotics for 4 to 8 weeks. Intraoperative cultures were positive in 6 patients. Results All infections resolved, with only 1 patient having complications—systemic sepsis and pneumonia. The mean ranges of motion were 146° of forward flexion (range, 135°-155°) and 48° of external rotation (range, 40°-55°), with the internal rotation level ranging from T5 to L3. The mean superior migration of the clavicle was 1.5 mm (range, 0-4 mm), and the mean visual analog pain score was 1.4 ± 0.7 (range, 0-2). Conclusion Resection arthroplasty in patients with septic SC joints results in relatively good shoulder function.

BACKGROUND Patients with multiple hereditary exostoses (MHE) frequently present with a genu valgum deformity. Temporary hemiepiphysiodesis, such as hemiepiphyseal stapling, is a relatively safe surgical method to correct angular deformities in skeletally immature patients, but its outcomes for genu valgum deformity in MHE patients have not been extensively reported. We investigated the outcomes of hemiepiphyseal stapling in MHE patients (MHE group) and compared those with the outcomes in patients with idiopathic deformities (idiopathic group) after adjusting for potential bias. METHODS Data from 70 limbs with genu valgum deformity (15 MHE and 55 idiopathic), which had undergone hemiepiphyseal stapling, were retrospectively reviewed. The outcomes were focused on the achievement of satisfactory correction and the velocity of correction. The independent effects of each characteristic on each outcome were investigated using multivariate analyses. The outcomes between the groups were also compared after 1:2 matching using propensity score analysis. RESULTS The mean valgus angle of the MHE group was 7.4±4.1 degrees at stapling and was corrected to 1.3±3.0 degrees at staple removal. The rate of satisfactory corrections was not different between the MHE and idiopathic groups (67% and 70%, respectively, P=0.820). However, the correction velocity was significantly lower in the MHE group than in the idiopathic group on both multivariate analysis (P=0.001) and matching comparison (4.4 vs. 7.9 degrees/y, P

Background: The aim of the present study was to evaluate the clinical value of using the lateral tibiocalcaneal (LTiC) angle, measured on a lateral radiograph made with the foot and ankle in maximal dorsiflexion, instead of the ankle dorsiflexion (ADF) angle, measured on physical examination, as a determining indicator of the need for percutaneous Achilles tenotomy after Ponseti serial cast treatment of idiopathic clubfoot. Methods: We identified patients with idiopathic clubfoot who had been treated at our institution between March 2006 and June 2012. After exclusion of patients with Dimeglio grade-I clubfoot and those followed for less than two years, 125 idiopathic clubfeet were evaluated. The clubfeet were grouped according to their LTiC and ADF angles, after which we evaluated the clinical outcomes of each group and investigated the prognostic effects of each angle-based decision regarding whether to perform percutaneous Achilles tenotomy. Results: Patients with a favorable LTiC angle (≤80°) showed no sagittal relapse even though none underwent percutaneous Achilles tenotomy. In contrast, patients with an unfavorable LTiC angle (>80°) had a high chance of sagittal relapse if percutaneous Achilles tenotomy had not been performed, even when they had a favorable ADF angle (≥15°). The LTiC-angle-based decision showed the most significant prognostic value in multivariate analyses of relapse-free and surgery-free survival rates. Conclusions: The LTiC angle measured on simple radiographs is a more objective and prognostic indicator of the need for percutaneous Achilles tenotomy, as compared with the ADF angle measured on physical examination, in patients with idiopathic clubfoot. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Study design A retrospective analysis of patients that underwent perioperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis. Objective To review the clinical and radiographic results of perioperative halo-gravity traction in several time periods. Summary of background data Few reports to our knowledge review the use of perioperative and intraoperative halo-gravity traction in this patient population. Methods A total of 33 patients with severe operative scoliosis, kyphoscoliosis, or kyphosis were studied based on hospital records, standing pretreatment, traction (before anterior/posterior fusion), postoperative (each stage), and final radiographs. Patients were analyzed by age at date of examination (range, 2-20 years; mean, 13.8 years), gender (18 male, 15 female), major coronal curve magnitude (range, 22 degrees-158 degrees; average, 84 degrees), major compensatory coronal curve magnitude (range, 8 degrees-123 degrees; average, 51 degrees), major sagittal curve magnitude (range, 13 degrees-143 degrees; average, 78 degrees), traction protocol, and procedure type. Halo-traction-related, short- and long-term complications were noted in each case. Results The major coronal curve reduced 38 degrees or 46% after posterior spinal fusion compared to pretreatment radiographs. At an average of 44 months radiographic follow-up (range, 24-107 months), the loss of correction averaged 7 degrees for major coronal curves and 4 degrees of thoracic kyphosis. Clinical complications were noted in the perioperative and long-term time periods. Conclusions The treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods, especially if there is a significant kyphosis or a history of intraspinal pathology. Halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize postoperative correction in this difficult population. There were no permanent neurologic deficits in this series.

This study analyzed the relationship between type of discoid lateral menisci and tear pattern. There were 108 consecutive cases (103 patients) with discoid lateral meniscus tear treated by arthroscopy. Regarding type of discoid meniscus (Watanabe's classification), 38 cases were "complete" and 70 cases "incomplete." There was no Wrisberg type. Tear patterns were classified into simple horizontal, complicated horizontal, longitudinal, radial, degenerative, and complex tear. The relationship between tear pattern and type of discoid menisci was statistically highly significant. Simple horizontal tear was found only in the complete type of case, and radial, degenerative, and complex tears were found only in the incomplete type of case. In the longitudinal tear, however, we found no correlation between tear pattern and type of discoid meniscus. In addition, the extent of meniscal resection was dependent on the tear pattern. Subtotal or total meniscectomy was performed significantly more frequently in longitudinal and complex tears. In radial and degenerative tears only partial meniscectomy was carried out. Complicated horizontal tears showed no difference in extent of resection. Among the 13 cases of simple horizontal tears partial meniscectomy was performed in 12 cases. These findings about relationship between the type of discoid menisci and tear pattern could be useful in planning operation and deciding extent of resection.

Background: We investigated radiographic changes of calcaneocuboid (CC) joint subluxation following calcaneal lengthening procedure for the treatment of pediatric planovalgus foot deformities. Methods: This study included 44 cases of planovalgus foot deformities in 24 patients with mean age of 9.7 (range, 8 to 13) years who underwent calcaneal lengthening between 1999 and 2011. The mean follow-up period was 25 (range, 12 to 159) months. Anteroposterior (AP) and lateral radiographs of the weight-bearing view of the foot from immediate postoperative, 3-month postoperative, and last follow-up evaluations were reviewed and also used for trend analysis. Percentage of CC joint subluxations was measured on both AP and lateral view of the foot. Correlations between the percentage of CC joint subluxation and follow-up periods were assessed. Results: All of the feet showed dorsal subluxation of their CC joint on the immediate postoperative lateral plain radiographs. The median percentage of dorsal subluxation of the CC joint improved from 26.0% (range, 10.0 to 67.0) at the immediate postoperative evaluation to 16.5% (range, 7.0 to 47.0, P = .0001) at the 3-month postoperative evaluation and to 11% (range, 2.0 to 30.0, P = .0003) at last follow-up. The trend analysis over time indicated that the CC joint subluxation percentage with calcaneal lengthening generally decreased over time ( rs = −.67, P = .001). No patients showed osteoarthritic changes in the CC joint or nonunion at the calcaneal osteotomy site at last follow-up. Conclusion: At midterm follow-up, the CC joint subluxation was gradually resolving over time, with no evidence of osteoarthritic change in the CC joint. Level of Evidence: Level IV, case series.

Background and purpose There is no consensus on how to predict residual equinovarus deformities after application of the Ponseti method. We assessed the prognostic value of clinical scoring systems, and also radiographic parameters that can be measured just before percutaneous Achilles tenotomy (PAT). Method We reviewed 50 cases of clubfoot in 35 patients who were treated using the Ponseti method, including PAT, to analyze the factors that are predictive of residual equinovarus deformities. Mean age at the time of PAT was 2.4 (1.4–3.5) months, and the mean follow-up period was 23 (9–61) months. We divided these cases into 2 groups according to the need for further surgery to treat the residual deformities. Results 40 feet with satisfactory results were included in group 1, whereas the remaining 10 feet that required further surgery for unsatisfactory residual deformities were included in group 2. We compared the initial Dimeglio and Pirani scores obtained before the first Ponseti casting, follow-up Pirani scores, and radiographic parameters determined just before PAT between these 2 groups. There was no statistically significant difference between the groups in terms of the initial Dimeglio and Pirani scores, although the follow-up Pirani scores and lateral tibiocalcaneal angle were higher and the lateral talocalcaneal angle was lower in group 2 at the time of PAT. Interpretation We conclude that the Pirani score, lateral tibiocalcaneal angle, and talocalcaneal angle, when assessed immediately before PAT, might be predictive factors for residual equinovarus deformity following Ponseti treatment for severe idiopathic clubfoot.

Regardless of the mode of treatment, clubfoot has a strong tendency to relapse, especially hindfoot equinus. Because contraction or shortening of the Achilles tendon causes an equinus deformity of the ankle, release of this tendon is required to correct equinus deformity in patients with residual or relapsed clubfoot. This study assessed the effectiveness of the Vulpius technique in correcting equinus deformity in patients with residual or relapsed clubfoot.Of the 80 idiopathic clubfeet treated conservatively using the Ponseti protocol, between March 2000 and July 2008, 32 were found to have residual or relapsed equinus deformity, with 22 feet in 17 patients undergoing Vulpius-type Achilles tendon lengthening. Mean age at the time of surgery was 29 (range, 6 to 52) months, and mean follow-up was 48 (range, 24 to 78) months. Clinical evaluation included the dorsiflexion angle of the ankle and radiographic evaluation included the talocalcaneal and tibiocalcaneal angles on dorsiflexion lateral views.All 22 feet showed satisfactory results at last follow-up, with significant improvements in mean ankle dorsiflexion angle, mean tibiocalcaneal angle, and mean lateral talocalcaneal angle (p.05 each).The Vulpius procedure is an effective surgical procedure for correcting equinus deformity in residual and relapsed clubfeet.

This experimental investigation was performed to study the development of a subchondral fracture after ischemic osteonecrosis of the immature femoral head using a piglet model. Forty-eight male piglets were studied after placing a ligature tightly around the femoral neck to disrupt the blood supply to the femoral head. Animals were euthanized 2-8 weeks after the induction of ischemia. Radiographic, histologic, and histomorphometric assessments were made. A subchondral fracture was seen in 12 out of 32 infarcted femoral heads (38%) that were in the initial radiographic stage of ischemic osteonecrosis. The fracture was seen mainly in those femoral heads that had a prolonged period of the initial stage where the initiation of revascularization and repair was delayed. Histomorphometric assessment showed decreased trabecular thickness and volume in the subchondral region of the infarcted femoral heads compared with the contralateral normal heads. After ischemic osteonecrosis, the trabecular bone in the subchondral region is thinner and less bone volume is present because of a lack of new bone formation. The results of this study support the hypothesis that a subchondral fracture in the immature femoral head develops as a result of mechanic failure of the trabecular bone in the subchondral region.

Background: The purpose of this study was to investigate the clinical and radiological results of calcaneal osteotomy, joint debridement and ligament reconstruction for the treatment of early to moderate stage osteoarthritis of the ankle. Materials and Methods: Eleven cases with osteoarthritis of the ankle, four with stage 2 and seven with stage 3, underwent joint debridement, cheilectomy, calcaneal osteotomy, deltoid ligament release, and lateral ligament reconstruction. The mean followup was 22.3 (range, 15 to 42) months. The American Orthopaedic Foot and Ankle Society(AOFAS) clinical ankle-hindfoot scale was used to evaluate clinical function of the ankle. Weight-bearing anteroposterior and hindfoot alignment radiographs were evaluated for measuring of tibiotalar tilt angles, clear space ratio, heel alignment ratio preoperatively and at the last followup. Results: The mean AOFAS score improved from 42.8 points before surgery to 82.7 points at the last followup. The mean talar tilt angles improved from 7.4 degrees to 5.9 degrees. The mean medial clear space widened from 0.4 mm to 2.7 mm. The lateral clear space was narrowed from 6.8 mm to 4.8 mm. The medial to lateral clear space ratio of ankle was improved from 0.06 to 0.62. Heel alignment ratio was improved from 0.59 to 0.36. Conclusion: Calcaneal osteotomy with ligament reconstruction can be considered for treatment of the early stages of osteoarthritis of the ankle.

Background: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. Methods: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. Results: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5thmetatarsal medial deviation occurred. Conclusions: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.

To develop a standard growth curve of the lower extremity in Korean children from 3 to 16 yr of age, the lengths from a total of 2087 normal long bone segments (582 femurs and 645 tibias in boys, and 417 femurs and 443 tibias in girls) were measured. Children were grouped by years of bone age, which was determined by using the Korean specific bone age standard; TW2-20 method. The growth spurt occurred in girls from eight to eleven years by bone age, and in boys from eleven to thirteen years. The mean tibial length relative to the mean femoral length was 0.78 in boys and 0.79 in girls. The overall growth pattern was similar to that observed in American children in the 1960s. Korean children and adolescents appear to have a different tempo of skeletal maturation during pubertal growth from that of English and American children and adolescents. The Korean standard growth curve and the Korean bone age chart allow determination of the presence of any existent growth abnormalities and prediction of future remaining growth in lower extremities. These normative growth standards can be used for leg-length equalization purposes in children with anisomelia.

목적: 소아에 있어 급성 화농성 고관절염이 의심되는 경우에 정확한 진단과 그에 따른 치료 방법을 결정하는데 있어서 자기공명영상의 유용성과 임상 결과를 평가하고자 하였다. 대상 및 방법: 2003년 3월부터 2007년 5월까지 급성 화농성 고관절염이 의심되어 자기공명영상 검사를 시행한 환아 20명을 대상으로 하였으며 평균 연령은 3년 5개월(10일-14세)이었으며 평균 추시 기간은 2년 2개월(1년-3년 6개월)이었다. 이들 환아에서 시행한 자기공명영상 소견 및 임상적 결과를 후향적으로 분석하였다. 결과: 자기공명영상 소견상 관절 삼출액이 증가가 있었던 예가 17예(85%)였으며, 그 중 골단이나 골간단부의 신호 강도 변화가 있었던 예가 7예, 주변 근육의 신호 강도 변화가 같이 있었던 예가 3예, 연부조직의 농양 형성이 있었던 경우가 1예 있었다. 관절 삼출액 증가 없이 관절 주변 근육내 농양으로 급성 화농성 고관절염과 유사한 임상증상을 일으킨 예가 3예(15%)있었다. 추시 결과 후유증으로 인한 골 변형을 보인 2예를 제외한 18예에서 진단에 유용한 정보를 제공하였다. 결론: 자기공명영상은 급성 화농성 고관절염의 감별 진단 뿐 아니라 주변 연부 조직이나 골 조직으로 확산된 감염 병소에 대한 유용한 정보를 제공해줄 수 있는 유용한 검사법이라 사료된다.

Purpose: We wanted to compare the outcome of the flexible intramedullary nailing with that of external fixation for treating pediatric femoral shaft fractures. Materials and Methods: Forty-two cases of pediatric femoral shaft fractures were reviewed of which thirty cases of femoral segments were treated with the flexible intramedullary nailing (the FIN group) and the other 12 cases were treated with the external fixation (the EF group). The average age of the patients was 6.9 years and the mean follow-up was 28.8 months. The clinical outcome and complications were evaluated. Results: In all cases, the reduction was maintained until complete union. In the FIN group there were 20 excellent, 8 satisfactory and 2 poor results whereas there were 6 excellent, 4 satisfactory and 2 poor results in the EF group. Among the complications that required re-admission, there was one case of refracture and one case of deep infection in FIN group; one case of refracture, one case of pin breakage and three cases of deep infections in the EF group. Conclusion: Flexible intramedullary nailing may result in better clinical results and fewer complications when compared with the external fixation, and so the flexible intramedullary nailing may be the treatment of choice for the treatment of pediatric femoral shaft fractures, except for open fractures or fractures with severe soft tissue injury.

Purpose : We compared the clinical results between arthroscopic multiple drilling and autologous osteochondral grafting for osteochondral lesions of the talus. Materials and Methods : Twelve patients underwent arthroscopic multiple drilling that left the remaining cartilage at the lesions, and ten patients underwent autologous osteochondral grafting for detached cartilage lesions. We performed a modified Brostrom procedure for 9 of the cases with combined lateral ankle instability in both groups. The average follow-up period was 12.4 months. The mean ages were 31 and 28 years old, respectively. The results were compared between the two groups by assessing the AOFAS scores and patient satisfaction, based on subjective symptoms. Results : The mean pre-operative AOFAS scores were 70 in the arthroscopic multiple drilling group and 70.3 in the autologous osteochondral grafting group. The post-operative AOFAS scores were 78.8 in the arthroscopic multiple drilling group and 93.5 in the autologous osteochondral grafting group (p＜0.05). Patient satisfaction after multiple drilling was good in 3 cases, fair in 4 cases, poor in 5 cases, and pre-operative symptoms were not improved at all in 4 cases. After autologous osteochondral grafting, 7 cases were good and 3 were fair. Conclusion : The study demonstrated that in the treatment of osteochondral lesions of the talar dome, the results of autologous osteochondral grafting were superior to those of arthroscopic multiple drilling.

Purpose : To investigate the factors that indicate the requirement of a bone marrow study for a diagnosis of acute leukemia in children with bone and joint pain. Materials and Methods : 170 children less than sixteen years old were diagnosed with acute leukemia. Eighteen (11%) of these patients, whose presenting complaints were pain in the extremities and back, were included in this study. The laboratory tests, radiographs and bone scan of patients were reviewed to identify the diagnostic clues that would indicate the need to perform a bone marrow study. Results : The mean age of the patients at the time of diagnosis was 6.8 years. The CBC test revealed abnormal findings such as anemia, leukocytosis/leukocytopenia or thrombocytosis/thrombocytopenia in 15 patients. The peripheral blood smear revealed immature blast cells in 14 patients. In the remaining 4 patients, MRI and bone scan revealed diagnostic clues of a hematological malignancy that indicated the need for a bone marrow study. Based on these diagnostic clues, a bone marrow study was performed to confirm acute leukemia. Conclusion : Orthopedic surgeons must have high index of suspicion of acute leukemia in children with atypical bone and joint pain. A complete blood count and peripheral blood smear may be used as a screening test, and MRI may be helpful for diagnosing acute leukemia.

Background The results of hemiepiphysiodesis for the treatment of late-onset tibia vara have been reported to be favorable, but the technique requires careful timing and an accurate estimation of skeletal age. Hemiepiphyseal stapling does not require a careful estimation of skeletal age, and it has been reported to yield good results with low morbidity. However, we are not aware of any study evaluating the intermediate-term radiographic results or complications of this procedure. Methods Twenty-six patients with thirty-three extremities with late-onset tibia vara were treated with proximal tibial hemiepiphyseal stapling. Fourteen extremities had substantial concomitant distal femoral varus and also had hemiepiphyseal stapling of the distal part of the femur. Eighteen patients (twenty-three involved extremities) had juvenileonset tibia vara and eight patients (ten involved extremities) had adolescent-onset tibia vara. The mean age at the time of stapling was 11.8 years. The mean duration of follow-up was 3.8 years. We reviewed standardized standing radiographs to determine the mechanical axis deviation, the medial proximal tibial angle, the lateral distal femoral angle, and the zone of the knee through which the mechanical axis passed. Results The mean mechanical axis deviation improved from 58 mm (range, 27 to 157 mm) preoperatively to 22 mm (range, -33 to 117 mm) at the time of the last follow-up, and the mean medial proximal tibial angle improved from 77 degrees (range, 50 degrees to 85 degrees ) to 85 degrees (range, 48 degrees to 95 degrees ). In the fourteen lower extremities in which distal femoral hemiepiphyseal stapling was performed, the mean lateral distal femoral angle improved from 96 degrees (range, 92 degrees to 100 degrees ) to 86 degrees (range, 79 degrees to 97 degrees ). At the time of the final follow-up, seven extremities were considered to be in moderate varus; four, in mild varus; twenty, in normal alignment; and two, in valgus. No differences in radiographic outcome were noted between the juvenile and adolescent forms of tibia vara. Only one of the four extremities with severe preoperative varus was corrected to normal alignment; the remaining three were left with moderate varus. Conclusions Hemiepiphyseal stapling of the lateral aspect of the proximal tibial physis and, as needed, the lateral aspect of the distal femoral physis is safe and effective in children with late-onset tibia vara if the physes are sufficiently open and the varus deformity is mild to moderate. Hemiepiphyseal stapling is particularly effective in patients who are ten years of age or younger. Level of evidence Therapeutic Level IV.