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Background: Abnormal angular and torsional alignment of the lower extremities during growth are a common reason for consultation of a paediatrician or orthopaedist. There is often uncertainty about the pathological value of these abnormalities and the need for treatment, even among specialists. In the course of physiological growth and development processes, the axial and torsional alignment of the legs sometimes change considerably and in characteristic patterns., Diagnostics: The ability to assess whether abnormal angular or torsional alignments of the lower limb in the course of growth should still be regarded as normal or already as pathological, depending on age and gender, is essential for the treating physician and requires precise knowledge of the physiological development processes and the tolerable limits in all three spatial dimensions., Treatment: After careful explanation to the frequently concerned parents, a restrictive approach with observation of the spontaneous course of correction on the basis of regular clinical check-ups makes sense in the majority of cases. Pathological deviations from the physiological conditions are rare overall, can be idiopathic or of secondary origin and should be further clarified diagnostically using imaging procedures. As conservative measures are ineffective, pronounced angular and/or torsional deformities of the legs requiring treatment can only be corrected by surgical intervention, even in children and adolescents. The surgical treatment modalities available are varied and differ in terms of their invasiveness and complication profile, depending on the localization, type and severity of the deformity, as well as the age and possible concomitant diseases of the affected child or adolescent., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Pathomechanics resulting from rotational deformities of the long bones in an idiopathic population have not been extensively studied, and are chiefly limited to level over ground walking. Thirty-five adolescents with excessive idiopathic outward tibial torsion (TT), femoral rotation, or both (pan genu) were studied both before and after corrective surgery. Data collected included computational motion analysis of a drop jump and patient-reported outcomes consisting of PODCI and Goal Attainment Scores. Results were compared to an age-matched typically developing cohort (n = 25). Subjects with femoral anteversion (FA) exhibited compensatory hip rotations to normalize knee progression angles at landing. Subjects with only TT did not compensate at the hip, landing with typical knee progression but excessive outward foot progression. These strategies resulted in elevated frontal plane knee moments for FA ( P  = 0.008), and elevated lateral knee forces in all groups compared to typical, with the TT group reaching significance ( P  < 0.001). Rotational osteotomies successfully restored elevated kinematics and kinetics to within or below typically developing ranges. Patient-reported outcomes generally improved after surgery across all domains studied. Drop jump testing elucidated compensation strategies employed by these cohorts. Compensation did not fully alleviate elevated forces at the knees. Surgical intervention normalized pathokinematics and pathokinetics, reduced pain, and improved patients' perception of their functional abilities. Greater improvements were found in individuals in the two groups with FA compared to the group with TT only., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Many patients who cannot squat well in a neutral toe position can only squat in an excessively out-toeing position. This excessive out-toeing squat is thought to be caused by rotational problems of the lower extremities. In this study, we aimed to identify the cause for the inability to squat by measuring and comparing femoral and tibial torsion between an excessive out-toeing squat patient group and a control group representing the general population. Between 2008 and 2022, a patient group comprising 50 lower extremities with excessive out-toeing squats was established. A control group representing the general population was selected from patients aged 0 to 29 years, who underwent lower-extremity CT angiography between 2012 and 2022, using the Clinical Data Warehouse with exclusion criteria applied. A total of 94 lower extremities were included in the control group. The femoral torsional angle (FTA) and tibial torsional angle (TTA) of both groups were measured and compared using Student t test. Additionally, 30 each of those with the highest and lowest 30 FTA values were selected from the patient and control groups, and the TTA was compared between the high- and low-FTA groups using Student t test. The mean FTA was 0.34° (SD, 11.11°) in the patient group and 10.14° (SD, 11.85°) in the control group, with a mean difference of 9.8° and P < .001. The mean TTA was 27.95° (SD, 7.82°) in the patient group and 32.67 ° (SD, 7.58°) in the control group, with a mean difference of 4.72° (P = .001). The mean TTA was 34.3° (SD, 7.72°) in the high-FTA group and 28.17° (SD, 8.35°) in the low-FTA group, with a mean difference of 6.13° (P = .005). Patients with excessive out-toeing squat showed lower FTA and TTA values than the general population. Furthermore, although a correlation between FTA and TTA was not established through Pearson correlation analysis, a tendency was observed where a decrease in FTA was associated with a decrease in TTA. Based on these results, decreased FTA was demonstrated to be one of the major causes of excessive out-toeing squats., Competing Interests: Each author certifies that there are no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Torsional deformities of the lower limbs in children and adolescents are a common cause of in-toeing gait and cause gait deviations. The purpose of this study was to examine the relationship of children and adolescents with suspected Idiopathic Torsional Deformities (ITD) and pain, gait function, activity and participation., Methods: A retrospective review of all children and adolescents who attended our Centre over a 5-year period for evaluation of the effect of ITD. All children completed three-dimensional gait analysis (3DGA), standardized physical examination, medical imaging and the Pediatric Outcomes Data Collection Instrument (PODCI). Statistical analysis was completed using two sample t-tests, Pearson's Correlation and linear regression., Results: Fifty children and adolescents, 40 females and 10 males with a mean age of 13.5 years were included. Children reported a high prevalence of pain(86%), had increased internal hip rotation(p = 0.002) and decreased external hip rotation(p < 0.001) on physical examination when compared to published normative data. Medical imaging showed a mean(SD) femoral neck anteversion (FNA) of 38°(13°) and external tibial torsion of 39°(12°). Mean(SD) PODCI score was 32(16), indicating these children are functioning below their typically developing peers. The 3DGA kinematics show deviations from typical data including hip rotation, foot progression, pelvic tilt, hip flexion and knee extension. Observed mild kinetic deviations were within typical limits. The relationship between FNA and gait parameters, FNA and PODCI and gait and PODCI were weak., Significance: These children and adolescents have altered gait and experience pain leading to impaired function and diminished participation. Therefore, ITD is not purely a cosmetic issue., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Individualized pre-operative assessment of the patterns of the lower extremity anatomy and deformities in patients undergoing total knee arthroplasty seems essential for a successful surgery. In the present study, we investigated the relationship among the coronal alignment and the rotational profile of the lower extremities in the Caucasian population with end-stage knee osteoarthritis. We conducted a prospective study of 385 knees that underwent a pre-operative three-dimensional computed tomography-based model. The lower extremity alignment was determined (mechanical tibiofemoral or hip-knee-ankle angle, supplementary angle of the femoral lateral distal angle, and proximal medial tibial angle). For each case, the femoral distal rotation (condylar twist angle), the femoral proximal version, and the tibial torsion were determined. As the coronal alignment changed from varus to valgus, the femoral external rotation increased (r = 0.217; p < 0.0005). As the coronal alignment changed from varus to valgus, the external tibial torsion increased (r = 0.248; p < 0.0005). No correlation was found between the global coronal alignment and the femoral version. The present study demonstrates a linear relationship between the coronal alignment and the rotational geometry of the distal femur. This correlation also occurs with the tibial torsion. Perhaps outcomes of total knee arthroplasty surgery might be improved by addressing these deformities as well.

The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However, although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention. We review cases with IFFI in order to identify specific involvement patterns. Cases of epiploic appendages reported to an acute, subacute, and more chronic phase in order to present the self-limiting nature of this entity and the resultant absorption. We also present cases with falciform ligament infarction, as well as primary ("whirl sign" on CT due to greater omentum torsion) and secondary omental infarctions. The aim of this pictorial review is not only to extensively explore the imaging findings of IFFI but to also describe the clinical presentation and pathophysiology of the prementioned conditions.

Measuring umbilical blood pressure in utero is challenging and for this reason non-invasive methods are required. However, the total vessel blood pressure drop can be estimated using numerical and empirical results by studying the mechanics of fluids in coiled and straight tubes. Two key findings emerge from such an analysis. Firstly, the total pressure drop along a vessel at a given blood flow-rate depends on both the tightness of the coils and the total cord length. Relatively short and straight cords exhibit low pressure, while long, tightly coiled cords with large width exhibit high pressure. It follows that an estimate of the pressure requires three measurements: the full cord length, its average width and number of coils. Using this result we propose two prototype indices for clinical testing that estimate umbilical cord flow resistance. The umbilical pressure index (P X ) and flow index (Q X ) quantify the deviation of a cord geometry from defined typical conditions by considering the steady pressure drop and flow-rate, respectively. These indices can be quickly calculated, and require only a single additional measurement to the conventional umbilical coiling index (UCI); namely the cord coiling width. Unlike the UCI, these indices are derived from blood-flow properties and provide a measure of the relative flow-resistance inherent to a cord geometry. Furthermore, the pressure index can be applied to irregularities, including loose true knots, which we show must be accounted for., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the outcomes of proximal femoral derotation osteotomy (PFDO) on the hip and spine function of patients with abnormal femoral torsion., Methods: This retrospective study included patients who underwent PFDO to treat increased or decreased femoral torsion between July 2014 and February 2019. The exclusion criteria were: previous fracture, fixation of slipped capital femoral epiphysis or osteotomy in the ipsilateral femur; PFDO associated to varus or valgus osteotomy; Tönnis grade 2 or 3 osteoarthritis; and PFDO performed to treat knee abnormalities. Hip function was assessed through the modified Harris Hip Score (mHHS). A subgroup of consecutive patients with low back pain before the PFDO and operated after 2017 had the spine function assessed through the Oswestry disability index (ODI)., Results: A total of 37 hips (34 patients) were studied: 15 hips with increased femoral torsion and 22 with decreased femoral torsion. Eight patients were male and 26 were female. The average age at PFDO was 33 years (range, 15-54 years). At a mean follow-up of 24 months (range, 12-65 months), the mean mHHS improved from 58.1 ± 14.3 before PFDO to 82 ± 15.6 at the most recent follow-up (P < .001). Improvement in the mHHS above the minimum clinically important difference (MCID) was observed in 33 hips (89%). In the subgroup of 14 consecutive patients with ODI available, the ODI improved from a mean of 45% ± 16% before the PFDO to 22% ± 17% at the most recent follow-up (P = .001). Nine (64.3%) of the 14 patients presented improvement in the ODI above the MCID. Revision procedure with a larger intramedullary nail was necessary in 2 hips to treat nonunion., Conclusion: Proximal femoral derotation osteotomy improves the hip and spine function in patients with increased or decreased femoral torsion and nonarthritic hips., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Significance: Ocular tilt reaction (OTR) is an abnormal eye-head postural reaction that consists of skew deviation, head tilt, and bilateral ocular torsion. Understanding of the pathway of the vestibulo-ocular reflex (VOR) is essential because this will help to localize the pathology., Purpose: The aim of this study was to report a case of OTR with contralateral internuclear ophthalmoplegia (INO) and fifth and seventh cranial nerve palsies., Case Report: A 51-year-old gentleman with underlying diabetes mellitus presented with sudden onset of diplopia for 3 days. On examination, his visual acuity was 20/30 bilaterally without a relative afferent pupillary defect. He had a right OTR consisting of a right head tilt, a skew deviation with a left eye hypertropia, and bilateral ocular torsion (right excyclotorsion and left incyclotorsion) with nystagmus. He also had a left adduction deficit and right abduction nystagmus consistent with a left INO. Ocular examination revealed evidence of proliferative diabetic retinopathy bilaterally. Two days after the initial presentation, the patient developed left seventh and fifth cranial nerve palsies. MRI showed left pontine infarction and multiple chronic lacunar infarctions. There was an incidental finding of a vascular loop compression on cisternal portions of the left trigeminal, facial, and vestibulocochlear nerves. Antiplatelet treatment was started on top of a better diabetic control. The diplopia was gradually resolved with improved clinical signs. In this case, the left pontine infarction had likely affected the terminal decussated part of the vestibulocochlear nerve from the right VOR pathway, medial longitudinal fasciculus, and cranial nerve nuclei in the left pons., Conclusions: The OTR can be ipsilateral to the lesion if the lesion is before the decussation of the VOR pathway in the pons, or it can be contralateral to the lesion if the lesion is after the decussation. In case of an OTR that is associated with contralateral INO and other contralateral cranial nerves palsy, a pathology in the pons that is contralateral to the OTR should be considered. Neuroimaging study can hence be targeted to identify the possible cause.

Purpose: Selection of the ideal procedure to correct symptomatic excyclotropia depends on several factors including the degree of torsion and associated vertical, horizontal and pattern deviation. Selective tuck of the anterior temporal torsional fibers of the superior oblique (SO) tendon is an alternative procedure to the classical Harada-Ito. The purpose of this study is to report its stability and results., Methods: Retrospective review of all consecutive patients with symptomatic excyclotorsion of at least 5º (degrees) treated by selectively splitting and tucking the anterior temporal fibers of the SO tendon. Torsion in primary position was measured using the double Maddox Rods. Patients with additional symptomatic vertical or horizontal diplopia underwent simultaneous surgery on other extraocular muscles., Results: Five patients were studied. Mean age was 60 ± 8 years (47-67). Mean postoperative follow-up was 10 ± 8 months (3-21). The mean preoperative torsion of 11º±4º (7º-15º) significantly decreased to 3º±2º ( p = .03) at the first postoperative visit (16 ± 9 days) and 3 ± 2º during the last visit ( P = .03). The procedure corrected 1.4º±0.9º per mm of tuck. Postoperatively no patient complained of torsion. No undesirable vertical or horizontal deviations were noted., Conclusion: This technique is a simple alternative to manage symptomatic excyclotorsion, with significant and stable relief of moderate amounts of torsion and without inducing unexpected vertical or horizontal deviation.

We investigated the effects of optimizing blood pressure control on cardiac deformation and vascular function. For this purpose, in 200 untreated patients with essential hypertension, we assessed at baseline as well as after 3 years of optimal blood pressure control: arterial stiffness and coronary microcirculatory function as well as longitudinal and torsional deformation parameters. Compared to baseline, after 3 years of optimal blood pressure control, there was an improvement of longitudinal strain, twisting as well as untwisting parameters of the left ventricle. In parallel, there was an improvement in coronary microcirculatory function, arterial stiffness, left ventricular mass, and ventricular-arterial interaction. The reduction of arterial stiffness was independently associated with the respective improvement of cardiac deformation markers and coronary flow reserve after adjusting for blood pressure improvement. Blood pressure optimization improves LV longitudinal and torsional mechanics in hypertensives in parallel with arterial stiffness, resulting in improved ventricular-arterial interaction and coronary flow reserve. Trial registration: ClinicalTrials.gov Identifier: NCT02346695.

Purpose: To determine the association between femoral torsion and anterior cruciate ligament (ACL) rupture and determine the level of torsion using magnetic resonance imaging (MRI)., Methods: The medical records of patients who were diagnosed with ACL injury were reviewed retrospectively. This descriptive epidemiological study included 2344 patients. MRI scans were examined and patients with femur and knee MRI scans obtained at the same time were identified (ACL-deficient group). Twenty-eight of them had femur and knee MRI scans because of an incidental benign lesion in the distal femur. Patients who were diagnosed with enchondroma were followed up by MRI evaluation of the femur and were randomly selected as controls. Supratrochanteric torsion (STT), infratrochanteric torsion (ITT), and femoral anteversion (FA) were measured by orthopedic surgeons with at least 5 years of experience., Results: Age, sex, and side properties were similar in both groups. The mean FA values were 19.4 ± 3.0 degrees and 11.9 ± 2.0 degrees in the ACL-deficient and control groups, respectively (p < 0.001). STT was similar in the ACL-deficient and control groups [mean: 38.2 ± 4.3 and 37.7 ± 3.3, respectively, (n.s.)]. ITT was increased in the ACL-deficient group compared with the control group (mean - 18.8 ± 4.3 and - 25.8 ± 3.8, respectively; p < 0.001)., Conclusions: According to our results, increased FA was associated with ACL rupture. Further, the torsional abnormality was developed from the ITT. We concluded that each ACL-deficient patient should be assessed by a clinician for torsional abnormality using physical examination., Level of Evidence: III.

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.

Background: Tibial torsion describes the rotation between the proximal and distal joint axis along the shaft, which can be, as rotational deformity, pathologically increased or decreased. Some patients might increase hip internal rotation during walking to compensate increased outward tibial torsion., Research Question: The aim of this study was to assess the effect of tibial derotation osteotomy on gait deviations in patients with increased outward tibial torsion., Methods: Thirteen patients (13.5 ± 1.4 yrs, 22 limbs) with increased tibial torsion (CT confirmed 49.2 ± 4.8°) were analyzed pre and post tibial derotation osteotomy and compared with 17 typically developing children (TDC, 13.5 ± 2.3 yrs, 32 limbs). Kinematic and kinetic data were recorded. Subgroup analyses were performed whether patients showed compensatory hip internal rotation (Comp) or not (NoComp). Principal component (PC) analysis was used to achieve data transformation. A linear mixed model was used to estimate the main effect of PC-scores of retained PCs explaining 90% of the cumulative variance., Results: Compensatory hip internal rotation (Comp, present in 45.5% of limbs analyzed) led to a lower external foot progression angle compared to patients without compensatory hip internal rotation (NoComp). In both patient groups foot progression angle was normalized after tibial derotation osteotomy. Post-operative NoComp had normalized frontal plane joint loadings, while Comp showed an increased hip and knee adduction moment., Significance: Future studies should investigate if more time is needed for Comp to normalize gait patterns post-operative or if a pre and post-operative gait training might help. Otherwise the increased knee adduction moment might be clinically relevant due to previous studies reporting a possible association with knee osteoarthritis., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: To evaluate the effect of cyclotorsion compensation with an image-guided system (Callisto eye; Carl Zeiss Meditec AG, Jena, Germany) on the visual and refractive outcomes of small incision lenticule extraction (SMILE) surgery for astigmatism., Methods: The medical records of 124 right eyes of 124 patients with astigmatism of 0.75 diopters (D) or greater who underwent SMILE for myopic astigmatism were reviewed. Patients were treated with cyclotorsion compensated SMILE or standard SMILE. After the sitting position reference axis was registered with IOLMaster 700 (Carl Zeiss Meditec AG), these data were transferred to the Callisto eye system, which was connected to the operating VisuMax microscope (Carl Zeiss Meditec AG). Cyclotorsion was measured by activating the Z-align function and compensated for by repositioning the patient's body or tilting the head until the reference axis from the IOLMaster 700 (0-180) was parallel to a manually drawn reference axis on the screen (0-180) before docking. The visual and refractive results were studied preoperatively and postoperatively. Astigmatic changes were interpreted using the Alpins method., Results: Six months after surgery, the results showed that the astigmatic eyes in the cyclotorsion compensated group had improved axial alignment, more precise astigmatic correction, and better postoperative uncorrected distance visual acuity (UDVA) compared with the standard group. The mean logMAR UDVA was 0.02 ± 0.10 (range: -0.15 to 0.30) and 0.06 ± 0.11 (range: -0.15 to 0.30) (P = .13) and the mean astigmatic error was -0.19 ± 0.17 D (range: -0.50 to 0.00 D) and -0.45 ± 0.38 D (range: -1.50 to 0.00 D) (P < .001) in the cyclotorsion compensated group and the standard group, respectively. In regard to vector analysis, the mean index of success was 0.00 ± 0.00 (range: 0.00 to 0.00) and 0.40 ± 0.48 (range: 0.00 to 2.72) (P < .001), and the mean absolute angle of error in degrees was 1.18 ± 2.23 (range: 0.00 to 13.00) and 3.76 ± 3.80 (range: 0.00 to 14.00) (P < .001) in the cyclotorsion compensated group and the standard group, respectively., Conclusions: The combination of the Callisto eye system with a VisuMax laser might be an efficacious and reliable approach to enhance astigmatism treatment with SMILE surgery. [J Refract Surg. 2020;36(3):142-149.]., (Copyright 2020, SLACK Incorporated.)

Background/purpose: The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion., Methods: A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients., Results: One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups., Conclusion: Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup., Type of Study: Retrospective comparative study., Level of Evidence: Level III., (Published by Elsevier Inc.)

Background: The importance of total ankle replacement (TAR) implant orientation in the axial plane is poorly understood with major variation in surgical technique of implants on the market. Our aim was to better understand the axial rotational profile of patients undergoing TAR., Methods: In 157 standardized computed tomography (CT) scans of patients with end-stage ankle arthritis planning to undergo primary TAR surgery, we measured the relationship between the knee posterior condylar axis, the tibial tuberosity, the transmalleolar axis (TMA), and the tibiotalar angle. The foot position was measured in relation to the TMA with the foot plantigrade. The variation between the medial gutter line and the line bisecting both gutters was assessed., Results: The mean external tibial torsion was 34.5 ± 10.3 degrees (11.8-62 degrees). When plantigrade, the mean foot position relative to the TMA was 21 ± 10.6 degrees (0.7-38.4 degrees) internally rotated. As external tibial torsion increased, the foot position became more internally rotated relative to the TMA (Pearson correlation, 0.6; P < .0001). As the tibiotalar angle became more valgus, the foot became more externally rotated relative to the TMA (Pearson correlation, -0.4; P < .01). The mean difference between the medial gutter line and a line bisecting both gutters was 4.9 ± 2.8 degrees (1.7-9.4 degrees). More than 51% of patients had a difference greater than 5 degrees. The mean angle between the medial gutter line and a line perpendicular to the TMA was 7.5 ± 2.6 degrees (2.8-13.7 degrees)., Conclusion: There was a large variation in rotational profile of patients undergoing TAR, particularly between the medial gutter line and the TMA. Surgeon designers and implant manufacturers should develop consistent methods to guide surgeons toward judging the appropriate axial rotation of their implant on an individual basis. We recommend careful clinical assessment and preoperative CT scans to enable the correct rotation to be determined., Level of Evidence: Level IIc, outcomes research.

Background/objectives: To compare ocular torsion between congenital and acquired unilateral superior oblique palsy (USOP)., Subjects/methods: Retrospective review was performed on medical records of 163 USOP patients. Qualitative fundus torsional states in both eyes were determined based on locations of optic disc and fovea. Disc-fovea angles (DFA) were collected in both eyes for quantitative analysis. DFAs and the proportions of qualitative fundus torsional states in paretic and non-paretic eyes were compared between USOP patients and normal controls, and between congenital and acquired USOP patients., Results: This study included 90 patients with congenital USOP, 73 patients with acquired USOP, and 66 normal controls. Most control subjects showed no torsion in both eyes (93.9%), whereas 61.1% of congenital and 46.5% of acquired USOP patients showed extorsion in either eye. More patients with congenital USOP showed fundus extorsion in the non-paretic eye (24.4% versus 12.3%) or both eyes (20.0% versus 6.8%), compared with patients with acquired USOP (P = 0.007). DFAs of paretic and non-paretic eyes were larger in USOP patients than in normal controls (P < 0.001, for both congenital USOP versus control and acquired USOP versus control). DFAs of non-paretic eyes were larger in congenital USOP patients than in acquired USOP patients (10.3° versus 8.5°, P = 0.018)., Conclusions: Congenital USOP showed greater fundus extorsion in the non-paretic eye, compared with acquired USOP. Fundus photographs of both eyes are necessary to understand the ocular torsion in USOP patients and the variations in fundus torsion with varying USOP aetiology.

Introduction: In patients with pelvic pain, corpus luteum with associated ovarian edema (CLOE) may be mistaken for ovarian torsion on ultrasound or CECT., Methods: This was a multi-reader, blinded, retrospective review performed at a single academic center from 2012 to 2018. Cases of CLOE that were misdiagnosed as torsion and cases of ovarian torsion without a lead-point mass were analyzed. Evaluated ultrasound features included presence of a corpus luteum, ovarian and corpus luteum volume, Color Doppler vascularity of the corpus luteum rim compared to that of the ovarian stroma, peripheral follicular displacement, twisted vascular pedicle, and free fluid. Evaluated CT features included presence of a corpus luteum, ovarian and corpus luteum volume, corpus luteum rim enhancement, twisted vascular pedicle, and free fluid., Results: 39 cases of CLOE and 30 cases of ovarian torsion without lead-point mass were reviewed. A corpus luteum was present in 56.7% of torsed ovaries. In CLOE cases, peripheral hypervascularity of the corpus luteum (manifested as enhancement at CECT or flow signal at Doppler US) was present in 67.7% (21/31) of cases on ultrasound, and in 95.7% (22/23) of cases on CT. No peripheral hypervascularity of the corpus luteum was seen in cases of torsion (p < 0.001). Torsed ovaries were significantly larger than CLOE cases. Other findings were not significantly different between the two groups., Conclusion: Increased blood flow in the periphery of a corpus luteum on color Doppler ultrasound or on CECT is a strong negative predictor for ovarian torsion.

A torsional wave (TW) sensor prototype was employed to quantify stiffness of the cervix in pregnant women. A cross-sectional study in a total of 18 women between 16 weeks and 35 weeks + 5 days of gestation was performed. The potential of TW technique to assess cervical ripening was evaluated by the measurement of stiffness related to gestational age and cervical length. Statistically significant correlations were found between cervical stiffness and gestational age ( R 2 = 0.370 , p = 0.0074 , using 1 kHz waves and R 2 = 0.445 , p = 0.0250 , using 1.5 kHz waves). A uniform decrease in stiffness of the cervical tissue was confirmed to happen during the complete gestation. There was no significant correlation between stiffness and cervical length. A stronger association between gestational age and cervical stiffness was found compared to gestational age and cervical length correlation. As a conclusion, TW technique is a feasible approach to objectively quantify the decrease of cervical stiffness related to gestational age. Further research is required to evaluate the application of TW technique in obstetric evaluations, such as prediction of preterm delivery and labor induction failure.

Background: Adnexal torsion constitutes 2.7% of all gynecological emergencies. Because normal follicular growth has been demonstrated after examination of surgical specimens retrieved from oophorectomies, organ-sparing strategy has gained more popularity irrespective of the appearance of the ovary. However, the functionality of the remaining follicles has not been known. The aim of the study was to evaluate the effect of ischemia-reperfusion on fecundability in a rat model with adnexal torsion., Methods: A total of 30 female adult Wistar albino rats were assessed. In the first laparotomy, right ovaries were twisted for 8 (Group I, n = 10) or 24 (Group II, n = 10) hours. Second laparotomy was performed to untwist the torsion side and oophorectomy to the other side. In the control group (Group III, n = 10), left ovaries were removed and right ovaries were kept without any intervention. After 30 days from the last operation, female rats were mated for 10 days and euthanized 4 days later. Fecundability was calculated using beta-human chorionic gonadotropin (hCG) levels for detection of pregnancy rates., Results: The mean beta-hCG values in control, 8-hour, and 24-hour groups between pregnant rats were 19.8 ± 26.02, 11.7 ± 0.17, and 22.97 ± 11.87 mIU/mL, respectively. Whereas two out of 10 rats (20%) conceived in the 8-hour group, three out of 10 rats (30%) got pregnant in the 24-hour group. In total, whereas five out of the 20 rats got pregnant in the experimental groups, in the control group, seven out of 10 subjects conceived (25% vs 70 %, p = 0.018)., Conclusion: Although there was a statistical difference between experimental and control groups, statistical significance was not reached among 8-hour and 24-hour torsion subgroups. In this context, patients with torsion but treated with detorsion should be further investigated for their fecundability potency and be informed accordingly.

Study Objective: To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery., Design: Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017., Setting: Large, tertiary care academic institution., Participants: We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT., Interventions: Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis., Main Outcome Measures: Characteristics predictive of OT in premenarchal girls., Results: Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group., Conclusion: Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular (LV) twist mechanics are augmented with both acute and chronic hypoxemia. Although the underlying mechanisms remain unknown, sympathetic activation and a direct effect of hypoxemia on the myocardium have been proposed, the latter of which may produce subendocardial dysfunction that is masked by larger subepicardial torque. This study therefore sought to (1) determine the individual and combined influences of β 1 -AR (β 1 -adrenergic receptor) stimulation and peripheral O 2 saturation (Spo 2 ) on LV twist in acute and chronic hypoxia and (2) elucidate whether endocardial versus epicardial mechanics respond differently to hypoxia., Methods: Twelve males (27±4 years) were tested near sea level in acute hypoxia (Spo 2 =82±4%) and following 3 to 6 days at 5050 m (high altitude; Spo 2 =83±3%). In both settings, participants received infusions of β 1 -AR blocker esmolol and volume-matched saline (double-blind, randomized). LV mechanics were assessed with 2-dimensional speckle-tracking echocardiography, and region-specific analysis to compare subendocardial and subepicardial mechanics., Results: At sea level, compared with baseline (14.8±3.0°) LV twist was reduced with esmolol (11.2±3.3°; P=0.007) and augmented during hypoxia (19.6±4.9°; P<0.001), whereas esmolol+hypoxia augmented twist compared with esmolol alone (16.5±3.3°; P<0.001). At 5050 m, LV twist was increased compared with sea level (19.5±5.4°; P=0.004), and reduced with esmolol (13.0±3.8°; P<0.001) and Spo 2 normalization (12.8±3.4°; P<0.001). Moreover, esmolol+normalized Spo 2 lowered twist further than esmolol alone (10.5±3.1°; P=0.036). There was no mechanics-derived evidence of endocardial dysfunction with hypoxia at sea level or high altitude., Conclusions: These findings suggest LV twist is augmented in hypoxia via β 1 -AR-dependent and β 1 -AR-independent mechanisms (eg, α 1 -AR stimulation), but does not appear to reflect endocardial dysfunction.

Background: Correct quantification of femoral torsion is crucial to diagnose torsional deformities, make an indication for surgical treatment, or plan the amount of correction. However, no clear evaluation of different femoral torsion measurement methods for hips with excessive torsion has been performed to date., Questions/purposes: (1) How does CT-based measurement of femoral torsion differ among five commonly used measurement methods? (2) Do differences in femoral torsion among measurement methods increase in hips with excessive femoral torsion? (3) What is the reliability and reproducibility of each of the five torsion measurement methods?, Methods: Between March and August 2016, we saw 86 new patients (95 hips) with hip pain and physical findings suggestive for femoroacetabular impingement at our outpatient tertiary clinic. Of those, 56 patients (62 hips) had a pelvic CT scan including the distal femur for measurement of femoral torsion. We excluded seven patients (seven hips) with previous hip surgery, two patients (two hips) with sequelae of Legg-Calvé-Perthes disease, and one patient (one hip) with a posttraumatic deformity. This resulted in 46 patients (52 hips) in the final study group with a mean age of 28 ± 9 years (range, 17-51 years) and 27 female patients (59%). Torsion was compared among five commonly used assessment measures, those of Lee et al., Reikerås et al., Jarrett et al., Tomczak et al., and Murphy et al. They differed regarding the level of the anatomic landmark for the proximal femoral neck axis; the method of Lee had the most proximal definition followed by the methods of Reikerås, Jarrett, and Tomczak at the base of the femoral neck and the method of Murphy with the most distal definition at the level of the lesser trochanter. The definition of the femoral head center and of the distal reference was consistent for all five measurement methods. We used the method described by Murphy et al. as our baseline measurement method for femoral torsion because it reportedly most closely reflects true anatomic femoral torsion. With this method we found a mean femoral torsion of 28 ± 13°. Mean values of femoral torsion were compared among the five methods using multivariate analysis of variance. All differences between two of the measurement methods were plotted over the entire range of femoral torsion to evaluate a possible increase in hips with excessive femoral torsion. All measurements were performed by two blinded orthopaedic residents (FS, TDL) at two different occasions to measure intraobserver reproducibility and interobserver reliability using intraclass correlation coefficients (ICCs)., Results: We found increasing values for femoral torsion using measurement methods with a more distal definition of the proximal femoral neck axis: Lee et al. (most proximal definition: 11° ± 11°), Reikerås et al. (15° ± 11°), Jarrett et al. (19° ± 11°), Tomczak et al. (25° ± 12°), and Murphy et al. (most distal definition: 28° ± 13°). The most pronounced difference was found for the comparison between the methods of Lee et al. and Murphy et al. with a mean difference of 17° ± 5° (95% confidence interval, 16°-19°; p < 0.001). For six of 10 possible pairwise comparisons, the difference between two methods increased with increasing femoral torsion and decreased with decreasing femoral torsion. We observed a fair-to-strong linear correlation (R range, 0.306-0.622; all p values < 0.05) for any method compared with the Murphy method and for the Reikerås and Jarrett methods when compared with the Tomczak method. For example, a hip with 10° of femoral antetorsion according Murphy had a torsion of 1° according to Reikerås, which corresponds to a difference of 9°. This difference increased to 20° in hips with excessive torsion; for example, a hip with 60° of torsion according to Murphy had 40° of torsion according to Reikerås. All five methods for measuring femoral torsion showed excellent agreement for both intraobserver reproducibility (ICC, 0.905-0.973) and interobserver reliability (ICC, 0.938-0.969)., Conclusions: Because the quantification of femoral torsion in hips with excessive femoral torsion differs considerably among measurement methods, it is crucial to state the applied methods when reporting femoral torsion and to be consistent regarding the used measurement method. These differences have to be considered for surgical decision-making and planning the degree of correction. Neglecting the differences among measurement methods to quantify femoral torsion can potentially lead to misdiagnosis and surgical planning errors., Level of Evidence: Level IV, diagnostic study.

Background: Left ventricular noncompaction cardiomyopathy (LVNC) is associated with poor clinical outcome in childhood. Standard diagnostic criteria are still controversial, especially in young patients. Recent studies in adults demonstrated that left ventricular (LV) twist is abnormal in LVNC, but it has not been investigated in pediatric patients to date. Our aim was to assess LV cardiac mechanics, LV twist, and the prevalence of rigid body rotation, using 2-dimensional speckle tracking echocardiography, in young patients with LVNC and LV hypertrabeculation., Methods: Forty-seven children (age range: 0-18 years) were assessed for suspected LVNC. All patients underwent 2-dimensional speckle tracking echocardiography and cardiovascular magnetic resonance imaging at 1.5 Tesla (T). Twenty-three patients fulfilled the cardiovascular magnetic resonance imaging diagnostic criteria for LVNC (LVNC group), while the remaining 24 did not and were included in the LV hypertrabeculation group. Forty-seven age- and sex-matched healthy volunteers were used as controls., Results: The average LV twist was significantly reduced in LVNC compared with control and LV hypertrabeculation. Rigid body rotation was recognized in 13 (56%) children with LVNC and in 1 (4%) child with LV hypertrabeculation and a strong family history for LVNC. Multivariable analysis demonstrated that LV twist is an independent predictor of LVNC ( P=0.006; coefficient=0.462). The receiver operating characteristics curve showed that LV twist had optimal predictive value to discriminate patients with LVNC (cutoff value <5.8°; sensitivity, 82%; specificity, 92%; area under the curve=0.914)., Conclusions: LV twist has good predictive value in diagnosing LVNC in young patients. Our findings strongly support the routine use of 2-dimensional speckle tracking echocardiography in the evaluation of young patients with suspected LVNC.

Purpose: To evaluate whether optic nerve head (ONH) tilt has relations with the visual field (VF) defect in myopic normal tension glaucoma (NTG)., Materials and Methods: Comparisons of variables were performed between less and more advanced VF defect groups in bilateral myopic NTG. Vertical, horizontal, maximal ONH tilt angles and angular location of maximal ONH tilt were measured using fundus photography and spectral-domain optical coherence tomography. Logistic regression analysis was performed to evaluate variables associated with more advanced VF defect in bilateral myopic NTG., Results: In total, 112 patients who have bilateral myopic NTG were included. Significant correlation was found between horizontal ONH tilt angle and angular location of maximal ONH tilt (R=0.45; P<0.001). In logistic regression analysis, a larger number of medications, greater horizontal ONH tilt, and greater angular location of maximal ONH tilt were associated with more advanced VF defect in myopic NTG (P=0.004, 0.014, 0.037, respectively). The location of VF defect was associated with the horizontal ONH tilt direction and angular location of maximal ONH tilt (κ=0.63, P<0.001; κ=0.48, P<0.001, respectively)., Conclusions: The horizontal ONH tilt and angular location of maximal ONH tilt correlated with the severity and location of VF defects in myopic NTG eyes.

Purpose: A medial patellofemoral ligament reconstruction (MPFL) with an additional derotational femoral osteotomy is suggested for patients suffering from patellar instability and an increased internal femoral torsion (IT). This biomechanical study investigated whether an isolated MPFL reconstruction could restore patellofemoral biomechanics for 10° and 20° relatively increased internal femoral torsion., Methods: Eight fresh-frozen cadaver knees were tested on a specially designed knee simulator, which bend the knee from 0° to 90° flexion. Patellar motion (tilt and shift) and patellofemoral pressure (pressure shift, mean and peak pressure) were evaluated for 0°, 10° and 20° of IT with a native and reconstructed MPFL., Results: An isolated MPFL reconstruction, compared to a native MPFL with the same femoral torsion showed a significant medial shift of the center of force (10° IT p < 0.001; 20° IT p = 0.02) and patella shift (10° and 20° IT p < 0.001) but no significant change in patella tilt (10° IT n.s.; 20° IT n.s.) for 10° and 20° IT. There was a significant medial shift in the center of force for 10° IT (10° IT p = 0.04) and a non-significant lateral shift for 20° IT (20° IT n.s.) in comparison to the native MPFL with 0° of femoral torsion. Patella shift was directed medially for 10° IT (10° IT p = 0.002). In knee flexion angles up to 30°, the patella remained more lateral for 20° IT and showed a different motion pattern (20° IT n.s.). Patella tilt showed a significant lateral tilt for 10° and 20° IT (10° IT p = 0.01; 20° IT p = 0.002)., Conclusion: MPFL reconstruction as an isolated therapy only appears to be reasonable for 10° increased IT. While for an increased IT of 20°, a lateralizing force vector remains and an additional femoral derotational osteotomy is recommendable. These findings may assist surgeons in the decision making of surgical procedures in patients suffering from patella instability.

Background: To compare clinical characteristics according to the laterality of objective ocular torsion in patients with unilateral superior oblique palsy (SOP)., Methods: This retrospective study included all patients with a diagnosis of unilateral SOP. They were classified into subgroups according to correspondence between the paretic eye and the extorted eye using fundus photography. Ocular alignment and muscle action were tested by the prism and alternate cover tests and 4-scale movement measure. Various clinical factors, including the amount of preoperative ocular torsion and change in ocular torsion postoperative, were compared between the accordance and disaccordance groups., Results: A total of 70 Asian patients (140 eyes) were included and underwent fundus photography preoperatively. Excyclotorsion in the paretic eye was defined as accordance (45 patients), excyclotorsion in the nonparetic eye was defined as disaccordance (25 patients). The presence of horizontal strabismus was detected in 28 (62%) patients in the accordance group and only 8 (32%) patients in the disaccordance group (p = 0.024). All horizontal strabismus observed in the accordance group involved exodeviation. The proportion of horizontal strabismus surgery was also significantly larger in the accordance group than the disaccordance group (p = 0.039). Among those patients, there were 26 who underwent fundus photography postoperatively. There was significant reduction in ocular excyclotorsion postoperatively in the accordance group (p = 0.001), but no significant reduction postoperatively in the disaccordance group (p = 0.270). There was no significant correlation between the amount of torsional reduction and the amount of vertical deviation reduction (p = 0.979)., Conclusions: In cases of preoperative excyclotorsion in paretic eyes, careful consideration of combined horizontal misalignment which may require surgical correction is helpful to manage unilateral SOP.

The aim of this study was to establish the torsional and toe-walking profiles of children with autism spectrum disorder (ASD), and to analyze the correlations between torsion, toe-walking, autism severity score, and age. In total, 79 consecutive children with autism were examined to determine their hip rotations, thigh-foot angle, degree of toe-walking, and autism severity. Femoral and tibial torsion values, of the preschool patients, were compared statistically with age-matched controls. The hip rotation profile of the patients was similar to the normal group. Nearly a half of the patients with ASD present excessive external tibial torsion. The difference in the tibial torsion between patients and normal children was statistically significant. A weak correlation was found only between tibial torsion and the autism severity score, but no correlation was found between the other parameters. External tibial torsion is the cardinal and persistent orthopedic manifestation among patients with ASD. Toe-walking is the second most common such manifestation and is an independent orthopedic feature in these patients. External tibial torsion may potentially contribute toward the described gait abnormalities in patients with ASD.

Study Objective: To compare the treatment and surgical outcomes of ovarian torsion in pregnant and nonpregnant women., Design: A population-based matched cohort study (Canadian Task Force classification II.1)., Setting: The United States Health Care Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2011., Patients: All cases of ovarian torsion among pregnant women and nonpregnant women with ovarian torsion (matched by age in a ratio of 1:1)., Interventions: Outcomes of interest included the type of treatment received for ovarian torsion and the complications of surgery., Measurements and Main Results: There were 1366 women diagnosed with ovarian torsion among 8 532 163 pregnant women for an incidence of 1.6 in 10 000. Surgery was the predominant treatment, with laparotomy being more commonly performed on pregnant women versus nonpregnant women (57.0% vs 51.0%; odds ratio = 1.28; 95% confidence interval, 1.08-1.51; p < .01). Overall conservative management was less likely performed; however, it was more common among pregnant women versus nonpregnant women (odds ratio = 1.85; 95% confidence interval, 1.44-2.37; p < .01). In general, adverse events were uncommon in both groups although ovarian infarction was more commonly reported among nonpregnant women., Conclusion: The diagnosis of ovarian torsion in pregnancy is rare. Compared with nonpregnant women, laparotomy and conservative management are more common among pregnant women. Treatment of ovarian torsion in pregnancy has comparable outcomes with treatment in nonpregnant women., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine demographic, surgical, and preoperative visual factors affecting the level of static and dynamic cyclotorsion (SC and DC) in eyes undergoing single-step transepithelial photorefractive keratectomy (TransPRK)., Methods: In this cross-sectional study, 386 patients with different types of refractive errors scheduled for single-step TransPRK were enrolled. A comprehensive profile of personal, optic, and visual characteristics of patients as surgical parameters were collected. Statistical modeling was used to explore correlates of SC and DC before and during the refractive procedure, respectively., Results: There was no difference in various indices of SC and DC between right and left eyes. Lower age (beta = -0.20), uncorrected (beta = -0.99) and corrected (beta = -0.72) visual acuities, and keratometry (beta = -0.09) were significantly associated with higher ranges of DC during the laser ablation procedure. Worse mesopic contrast sensitivity (beta = 0.24) and higher (beta = 0.002, left eyes) or lower (beta = -0.002, right eyes) kappa locus also showed significant associations with a higher range of DC. In cases of SC before the procedure, amount (beta = 0.46) and axis (beta = -0.003) of the astigmatism demonstrated notable associations., Conclusions: Through comprehensive modeling, age, visual axis indices, visual acuity, and contrast sensitivity were found to be the main factors significantly associated with dynamic ocular globe cyclotorsions during single-step TransPRK. This could help identify eyes at higher risk of cyclotorsion and its potential complications in refractive surgery. [J Refract Surg. 2018;34(11):736-744.]., (Copyright 2018, SLACK Incorporated.)

The craniovertebral junction (CVJ) is the bony transition between the cranium and cervical spine. It is a biomechanically complex articulation comprising the occipital condyles (Oc) the atlas (C1) and axis (C2). Pathologies affecting the CVJ in children are myriad with clinical features resulting from biomechanical instability, deformity, or neuraxial compression. Establishing the natural history and clinical burden of a condition is challenging in infants and young children, often complicated by co-existing neuromuscular and cognitive impairment. This makes investigation and treatment planning difficult. Each disease entity has a predilection for a particular biomechanical abnormality. Investigation using dynamic imaging is most appropriate in instability, computed tomography examination in abnormalities of deformity and magnetic resonance imaging examination in neuraxial compression. Treatment comprises reduction and immobilisation of instability, re-alignment of deformity, or decompression of the neuraxis. We present a review of disease entities affecting the CVJ in children categorised according to a simple mechanistic approach to aid investigation and treatment planning., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Purpose: To analyse objective ocular torsion among patients with infantile esotropia and to determine the effects of unilateral horizontal rectus surgery., Methods: Sixty-eight patients (136 eyes) (range 4 to 16 years) who underwent unilateral horizontal rectus surgery for infantile esotropia participated in this retrospective single-centre study. Objective ocular torsion using fundus photography was assessed before surgery and 1 year later. We defined three groups of patients based on preoperative qualitative objective ocular torsion: physiological extorsion and pathological extorsion and intorsion. For each group, the disc-foveal angle was measured and analysed both before and after surgery. We looked for possible correlations between amount of esodeviation and disc-foveal angle size., Results: Preoperatively, 28 (41%) patients had + 6.73 (± 2.66) degrees of physiological extorsion. Thirty-one (46%) patients had + 12.94 (± 3.67) degrees of pathological extorsion. Nine (13%) patients had - 1.99 (± 2.52) degrees of intorsion. After surgery, the number of subjects with physiological extorsion increased to 45 (66%). The number of patients with pathological extorsion decreased to 17 (25%) and the mean disc-foveal angle was significantly reduced by 1.80°. Six (9%) patients presented intorsion and the mean disc-foveal angle was significantly reduced by 2.28°. For the pathological extorsion group, the size of the disc-foveal angle before surgery was positively correlated to its reduction after surgery. Disc-foveal angle variation and distance esodeviation variation after surgery were positively correlated., Conclusions: These results highlight that pathological objective ocular torsion can be frequently found in infantile esotropia and is decreased after unilateral recession-plication surgery.

Objective: Accuracy of ultrasound in diagnosis of ovarian torsion remains controversial, with some studies reporting correct diagnosis in only 23% to 66% of cases. Normal Doppler flow does not necessarily exclude an ovarian torsion; in fact, it may lead to missing the diagnosis and has been show to delay management. The objective of our study was to assess sensitivity and specificity of ultrasound diagnosis of ovarian torsion and to analyze the factors contributing to correct and incorrect diagnosis., Methods: All women presenting with abdominal pain and admitted for urgent/emergent surgery to the gynaecology service at a major teaching hospital between September 2010 and August 2015 were reviewed. Of those, 55 cases of surgically proven ovarian torsion and 48 control cases were selected. Ultrasound reports were reviewed and analyzed., Results: Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Presence of ovarian cysts was significantly associated with torsion. Sensitivity of ultrasound was 70% and specificity was 87%., Conclusion: While ultrasound can be used to support a diagnosis of ovarian torsion, it is a clinical diagnosis that requires integration of many factors, especially patient presentation and exclusion of other non-gynaecological pathologies. Doppler flow is not a useful variable to diagnose or exclude ovarian torsion and we recommend it should not be used to exclude a diagnosis of ovarian torsion., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of our study was to evaluate a novel measurement technique for assessing the supra- and infratrochanteric components of femoral torsion, establish reference values in healthy volunteers, and compare supra- and infratrochanteric torsion angles in patients with hip dysplasia and patients with femoroacetabular impingement (FAI) with those in healthy volunteers., Materials and Methods: Femoral torsion was assessed in 380 patients and 61 healthy volunteers on MRI. For assessing supra- and infratrochanteric torsion, three measurement techniques (i.e., Kim, simplified Kim, and centroid methods) were evaluated by two readers on 100 patients. The technique with the highest interreader reliability was selected to perform measurements on all patients and volunteers. Supra- and infratrochanteric torsion angles of patients were stratified by hip disorders, which were diagnosed by specialized hip surgeons, and were compared with reference values of healthy volunteers. Statistical analysis included the independent t test, Mann-Whitney U test, and intraclass correlation coefficient (ICC)., Results: The centroid method showed the highest interreader reliability for measuring supra-and infratrochanteric torsion with an ICC of 0.979. The supra- and infratrochanteric torsion values of the volunteers were 31.5° ± 7.4° (mean ± SD) and -18.3° ± 9.9°, respectively. In comparison with the volunteers, patients with hip dysplasia had significantly higher supraand infratrochanteric torsion values of 37.5° ± 10.3° (p = 0.001) and -9.6° ± 11.7° (p < 0.001) and patients with pincer-type FAI had significantly higher supratrochanteric torsion values of 37.8° ± 8.0° (p = 0.002)., Conclusion: The supra- and infratrochanteric components of femoral torsion differ substantially between hip disorders: Patients with hip dysplasia have predominantly increased infratrochanteric torsion, whereas patients with pincer-type FAI have increased supratrochanteric torsion. Quantification of separate supra- and infratrochanteric torsion angles allows a more detailed analysis of hip disorders and may influence treatment planning.

Background: Torsional deformities of the femur and tibia are associated with gait impairments and joint pain. Several studies have investigated these gait deviations in children with cerebral palsy. However, relatively little is known about gait deviations in children with idiopathic torsion and debate ensues about the management of these patients., Research Question: What are the effects of idiopathic increased femoral neck anteversion and external tibial torsion on lower-limb kinematics, kinetics and joint loading during gait in children and adolescents., Methods: Patient-specific musculoskeletal models were created for 12 children/adolescents (mean age of 14 years) with torsional deformities using low-dose biplane radiographic imaging and 3D gait analysis. Comparisons of joint motion and net joint torques during gait were made to an age-matched control group with no torsional deformities. The effects of torsional deformities on muscle and joint contact forces were investigated using two personalised musculoskeletal models: one with normal torsion and another with patient-specific torsion., Results: Femoral neck anteversion and external tibial torsion for the patients were (mean ± SD) 38° ± 9° and 40° ± 10°, respectively. Patients had increased internal hip rotation and external knee rotation as well as increased pelvic tilt during gait. Additionally, the efficacy of the plantarflexor-knee extension mechanism was diminished. Hip joint contact force was higher in the model with patient-specific torsion. The mediolateral component of the patellofemoral joint contact force was also increased despite the magnitude of the resultant patellofemoral contact force being unchanged., Significance: It has been previously established that idiopathic lower-limb torsional deformities alter gait kinematics. However, this study also showed that loading of the hip and patellofemoral joints are increased. This is an important insight for the clinical management of these patients and highlights that idiopathic lower-limb torsional deformities are not a purely cosmetic issue., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The tibial tubercle deviation associated with recurrent patellar dislocation (RPD) has not been studied sufficiently. New methods of evaluation were used to verify the extent of tubercle deviation in a group with patellar dislocation compared with that in a control group, the frequency of patients who demonstrated a cutoff value indicating that tubercle transfer was warranted on the basis of the control group distribution, and the validity of these methods of evaluation for diagnosing RPD., Methods: Sixty-six patients with a history of patellar dislocation (single in 19 [SPD group] and recurrent in 47 [RPD group]) and 66 age and sex-matched controls were analyzed with the use of computed tomography (CT). The tibial tubercle-posterior cruciate ligament (TT-PCL) distance, TT-PCL ratio, and tibial tubercle lateralization (TTL) in the SPD and RPD groups were compared with those in the control group. Cutoff values to warrant 10 mm of transfer were based on either the minimum or -2SD (2 standard deviations below the mean) value in the control group, and the prevalences of patients in the RPD group with measurements above these cutoff values were calculated. The area under the curve (AUC) in receiver operating characteristic (ROC) curve analysis was used to assess the effectiveness of the measurements as predictors of RPD., Results: The mean TT-PCL distance, TT-PCL ratio, and TTL were all significantly greater in the RPD group than in the control group. The numbers of patients in the RPD group who satisfied the cutoff criteria when they were based on the minimum TT-PCL distance, TT-PCL ratio, and TTL in the control group were 11 (23%), 7 (15%), and 6 (13%), respectively. When the cutoff values were based on the -2SD values in the control group, the numbers of patients were 8 (17%), 6 (13%), and 0, respectively. The AUC of the ROC curve for TT-PCL distance, TT-PCL ratio, and TTL was 0.66, 0.72, and 0.72, respectively., Conclusions: The extent of TTL in the RPD group was not substantial, and the percentages of patients for whom 10 mm of medial transfer was indicated were small., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial femoral torsion (MFT) is a common pathologic gait in cerebral palsy (CP) children that can be corrected by femoral derotational osteotomy (FDO). It is not clearly known as to how much various gait parameters change after FDO. The aim of this study was to quantify changes in gait parameters after FDO. The study group included 19 young CP patients (28 limbs, age<20 years, average age: 13.2 years) with symptomatic MFT, treated with distal FDO. The study group was divided into two groups: the unilateral FDO group (UG) and the bilateral FDO group (BG). The mean degree of derotation was 24.6° (25.0° for UG, 24.4° for BG). Pre-FDO and post-FDO values of Staheli's rotational profiles and kinematic data were compared. A paired t-test and Pearson's correlation were used for statistical analysis. The mean internal hip rotation was 71.4±6.9° before surgery and 48.6±10.7° after surgery in the UG (P<0.05) and it was 63.8±15.8° before surgery and 40.9±9.2° after FDO in the BG (P<0.05). The change in the foot progression angle (FPA) was 12.9° in the UG group (P<0.05) and 12.6° in the BG group (P<0.05). The degree of FPA had changed by about a half of the surgical derotation angle. Changes in the mean hip rotation during gait were 14.8° in the UG (P<0.05) and 6.7° in the BG (P<0.05) groups. The overall pelvic rotation was not changed after surgery. However, in patients with preoperative compensatory pelvic rotation of more than 5°, there was a change of 5.3±4.8° in the UG and 6.6±1.54° in the BG after surgery (P<0.05). There was also a trend showing that the younger the patient, the more the pelvic rotation changed (P=0.069). In-toeing gait because of MFT improved with FDO in CP patients. The expected degree of postoperative correction of FPA and hip rotation is about a half of the FDO degree. The degree of compensatory pelvic rotation should be considered to determine the correction angle of FDO, especially in young patients with preoperative pelvic rotation of more than 5°.

Background: Multiple measurement methods are available to assess transverse plane alignment of the lower extremity., Research Question: This study was performed to determine the extent of correlation between femoral anteversion assessment using simultaneous biplanar radiographs and three-dimensional modeling (EOS imaging), clinical hip rotation by physical examination, and dynamic hip rotation assessed by gait analysis., Methods: Seventy-seven patients with cerebral palsy (GMFCS Level I and II) and 33 neurologically typical children with torsional abnormalities completed a comprehensive gait analysis with same day biplanar anterior-posterior and lateral radiographs and three-dimensional transverse plane assessment of femoral anteversion. Correlations were determined between physical exam of hip rotation, EOS imaging of femoral anteversion, and transverse plane hip kinematics for this retrospective review study., Results: Linear regression analysis revealed a weak relationship between physical examination measures of hip rotation and biplanar radiographic assessment of femoral anteversion. Similarly, poor correlation was found between clinical evaluation of femoral anteversion and motion assessment of dynamic hip rotation. Correlations were better in neurologically typical children with torsional abnormalities compared to children with gait dysfunction secondary to cerebral palsy., Significance: Dynamic hip rotation cannot be predicted by physical examination measures of hip range of motion or from three-dimensional assessment of femoral anteversion derived from biplanar radiographs., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The foveo-papillary angle (FPA) on fundus photographs is the accepted standard for the measurement of ocular cyclotorsion. We assessed the inter-rater reliability of this method in healthy subjects and in patients with trochlear nerve palsies., Patients and Methods: In this methodological study, fundus photographs of healthy subjects and of patients with trochlear nerve palsies were made with a fundus camera (Zeiss Fundus Camera FF 450 plus, Jena, Germany). Three independent observers measured the FPA on the fundus photographs of all subjects in synedra View (synedra View 16, Version 16.0.0.11, Innsbruck, Austria)., Results: One hundred and four eyes of 52 subjects (26 healthy controls and 26 patients) were assessed. The mean FPA of the healthy controls was 5.80 degrees (°) [± 0.44 standard error of the mean (SEM)] compared to 11.55° (± 0.80 SEM) for patients with trochlear nerve palsies. The inter-rater reliability of all measured FPAs showed an intraclass correlation coefficient (ICC) of 0.98 (95% CI 0.97 - 0.98)., Conclusions: The inter-rater reliability of objective cyclotorsion measurements using fundus photographs was very high., Competing Interests: GLT is supported by Filling the Gap of the University of Zurich, and has received speaker honoraria and a travel grant from Santhera. There is no conflict of interest regarding the published work. MD and MK have nothing to declare., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine predictive factors for intra-operative cyclotorsion in photorefractive keratectomy (PRK)., Methods: A retrospective statistical analysis of medical records pertaining to 3,996 eyes undergoing PRK was conducted. Outcome measures of this study were the likely existence of statistically significant relations between diverse and potentially influential factors and the occurrence of intraoperative cyclotorsion., Results: A total of 96% of examined medical records indicated some degree of cyclotorsion with the absolute mean intraoperative value of 1.38° ± 1.67° (range: 0° to 13.6°). Absolute mean cyclotorsion showed no significant correlation with age (r = 0.14, P = .37). Female patients had significantly higher degrees of cyclotorsion versus males (P < .001). Right and left eyes showed no significant difference in absolute mean torsion (P = .05). Higher diopters of refractive errors, hyperopia, more than 2.00 diopters of cylinder, high pulse numbers (r = 0.26), and use of the advanced personalized treatment ablation algorithm were all significantly related to higher degrees of torsion (P < .0001). Ablation depth (r = 0.13) and surgeon appeared to be dependent factors., Conclusions: Incidence of intraoperative cyclotorsion is high in eyes undergoing PRK and most of them will experience some degree of torsion. Several diverse factors (sex, refractive error diopters, hyperopia, high cylinder, pulse numbers, and ablation algorithm) were significant predictors for higher degrees of the observed torsion. [J Refract Surg. 2018;34(2):106-112.]., (Copyright 2018, SLACK Incorporated.)

Described in the article are the results of using ultrasonographic duplex scanning for studying anatomical peculiarities of the precanal segment of the human vertebral artery., Patients and Methods: Ultrasonographic duplex scanning (USDS) of the extracranial portions of brachiocephalic vessels was performed in a total of 215 inpatients without haemodynamically significant stenoses of the arteries of the vertebrobasilar basin. The patients found to have pathological alterations in the vertebrobasilar basin were excluded from the examined group. We studied the first segment of the vertebral artery from the origin to its entry into the canal of the transverse processes of cervical vertebrae (V1 segment according to the ultrasonographic nomenclature). We measured the diameter of the vertebral artery, assessing the pattern the vessel's passage, presence of pathological tortuosity, topographic interrelations between the V1 segment of the vertebral artery and structures of the neck, as well as analysing age-specific alterations in the anatomy of the vertebral artery., Results: By means of duplex scanning we in a non-invasive manner managed to gain a deeper insight into the anatomical peculiarities of the passage and structure of the initial portion of the human vertebral artery, as well as the differences in the structure between the contralateral vertebral arteries. We determined the average values of the diameters of the vertebral artery, its area, topographical relationships with the surrounding anatomical reference points along the length of the precanal segment, available for visualization by this method of study, and age-related peculiarities of the anatomy of the vertebral artery., Conclusions: Ultrasonographic duplex scanning of the extracranial portions of brachiocephalic vessels in humans is an effective, available and accurate technique making it possible to assess the anatomy of the initial portion of the vertebral artery. The average values of the diameters and area of the transverse section of the left vertebral artery turned out to be significantly greater than similar values of the right vertebral artery in the overwhelming majority of cases. Due to structural peculiarities of the aortic arch branches, in particular, independent origin of the left subclavian artery from the aortic arch, the left vertebral artery has, as a rule, greater length than the right one and differs by the topographical correlations with the surrounding structures on the neck, which is confirmed by the ultrasonographic method of study. The ultrasonographic method of study makes it possible to sufficiently effectively assess the difference in depth of the passage of the trunk of the vertebral artery in tissues of the fascial spaces of the neck in representatives of various types of the body-build. We also revealed a tendency towards a tortuous passage of the vertebral artery in the precanal segment in 35-44% of cases irrespective of the body-build, age and gender.

Background: People with neck pain (NP) experience sensorimotor and oculomotor deficits thought to be due to abnormal cervical afferent input. Convergence insufficiency (CI) measured by near point convergence (NPC) may be a feature in NP and neck torsion might help to differentiate a cervical cause., Objectives: This study aimed to investigate repeatability and reliability of NPC in neutral and torsion and compare between idiopathic NP and controls along with correlation to the Convergence Insufficiency Symptom Survey (CISS)., Design: Comparative cross sectional observational study., Method: A Royal Airforce (RAF) Rule measured NPC with the neck in neutral and in 45° torsion to the left and right in 42 subjects. A revised 15 item CISS was also completed. The average of 3 trials in each position and torsion difference were calculated. Within one week, NPC inter-rater and test-retest reliability was evaluated in 10 subjects., Results: A significant NPC torsion difference was demonstrated in participants with NP compared to controls (P = 0.01). No significant differences were seen for NPC values in neutral (P = 0.73). High inter-rater reliability (ICC = 0.95) and repeatability (ICC = 0.84) was obtained. No correlations were present between the CISS and NPC measures (r ≤ 0.18)., Conclusions: NPC is impaired in neck torsion compared to neutral in NP supporting a cervical afferent cause. NPC, measured using the RAF Rule, is a reliable and repeatable measure and can be used to assess NPC and CI in those with NP. Objective rather than self-reported measures should be used to examine CI in NP., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

PurposeThe double Maddox-rod test (DMRT) and Lancaster red-green test (LRGT) are the most widely used tests worldwide to assess subjective ocular torsion. However, these tests require equipment and the quantified results of ocular torsion are only provided in rough values. Here we developed a novel computerized torsion test (CTT) for individual assessment of subjective ocular torsion and validated the reliability and accuracy of the test compared with those of the DMRT and LRGT.MethodsA total of 30 patients with cyclovertical strabismus and 30 controls were recruited. The CTT was designed using Microsoft Office PowerPoint. Subjects wore red-green filter spectacles and viewed gradually tilted red and cyan lines on an LCD monitor and pressed the keyboard to go through the slides, until both lines seemed parallel. All subjects underwent the CTT, DMRT, and LRGT. Intraclass correlation coefficients and Bland-Altman plots were analyzed to assess the acceptability of the CTT compared with that of the DMRT.ResultsBoth the DMRT and CTT showed no significant test-retest differences in the strabismus and control groups. The DMRT and CTT results demonstrated an acceptable agreement. The reliability of the CTT was better than that of the DMRT. The LRGT showed low sensitivity for the detection of ocular torsion compared with the DMRT (40.0%) and CTT (39.1%).ConclusionOur results suggest that the assessment of subjective ocular torsion using the CTT based on PowerPoint software is simple, reproducible, and accurate and can be applied in clinical practice.

Abnormal tibial torsion is a common pediatric problem, and there are many existing measurement methods. The purpose of this study was to compare three methods of measuring tibial torsion for its evaluation: computed tomography, physical examination, and motion capture. Twenty healthy children and 20 children with myelomeningocele underwent measures of tibial torsion bilaterally. Measurements were compared using correlation and Bland-Altman plots of the difference between measurements. All three measurements were moderately correlated in controls (r ≥ 0.49, P ≤ 0.002) and in patients (r ≥ 0.51, P ≤ 0.001). In controls, the motion capture measurements were on average 2° more lateral than the clinical measurements whereas motion capture and clinical measurements were 13° and 15° more medial than CT measurements, respectively. Similarly for patients, motion capture measurements were on average 5° more medial than clinical measurements, and motion capture and clinical measurements were 26° and 22° more medial than CT measurements. The approximate 20° difference between the clinical or motion capture measures and the CT measure suggests that clinical evaluation identifies different axes than those defined based on skeletal anatomy. Clinical or motion capture methods may be used in lieu of imaging methods for measuring tibial torsion with the knowledge that these methods provide less lateral measurements than measurements obtained using CT. Clin. Anat. :1043-1048, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Internal tibial torsion (ITT) is a common boney deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome after external TDO performed to correct ITT in ambulatory children with CP., Methods: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ITT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing the subjects mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, preop MTR (at E0), preop gait velocity (at E0), gross motor function classification system score, and foot deformity were evaluated to determine their influence on long-term results., Results: The study sample consisted of 36 legs (with E0 and E2) and 17 legs (with E0, E1, and E2). The mean age at surgery was 7.4±2.8 (range, 4 to 16.6) years. Comparing the changes over time, kinematic MTR improved from 17±11 degrees initially (E0) to -10±14 degrees short term (E1) and progressed to -23±13 degrees long term (E2) (P<0.05 E0/E1/E2; internal rotation is positive). At E2, 16 legs (44%) were found to be in the kinematic corrected group and 20 legs (56%) in the kinematic overcorrected group. There were no significant differences between the corrected and overcorrected groups of children in respect to age of surgery, gross motor function classification system, E0 MTR, gait velocity, or foot deformity., Conclusions: Although external TDO is an accepted form of treatment in children with CP, in the long term a tendency to move into external tibial torsion is common. Therefore, caution is warranted with children who initially present with ITT to avoid overcorrection., Level of Evidence: Level IV-therapeutic study.