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Purpose/objective(s)Radiographic MRI response following prostate radiotherapy, particularly stereotactic body radiotherapy (SBRT), remains poorly understood. Our objective was to describe radiographic changes to the prostate gland and prostate tumor following SBRT of men treated on a prospective, randomized trial.Materials/methodsMIRAGE (NCT04384770) is a single center, randomized phase III trial of patients receiving either CT or MRI guided SBRT for localized prostate cancer. Patients underwent pre-treatment and annual post-treatment MRIs, in addition to routine PSA surveillance. Outcomes reported include percent gland shrinkage, percent PSA response at one year, and presence of residual tumor based on radiographic interpretation. Patient characteristics were compared via two-sample t-test or Fischer's exact test. Both univariate and multivariable logistical analysis were employed to identify potential clinical predictors of residual tumor on 1-year follow up MRI.ResultsThis study cohort included 94 eligible patients with baseline characteristics in Table 1. Residual lesions were seen in 13 patients (14%), 5/27 (18.5%) treated without ADT and 8/67 (12%) with ADT. PSA ablation was deep, with a 79% median decrease without ADT and 98% median decrease with ADT. Patients receiving ADT showed more gland shrinkage (17% vs. 34% shrinkage, p = 0.0001), while radiographic non-responders and responders experienced similar gland shrinkage (median 21% vs 29% shrinkage, p > 0.05). No significant clinical predictors of residual tumor were identified on univariate and multivariate analysis. No patient had any clinical or biochemical evidence of failure.ConclusionA total of 14% of patients were found to have residual tumor detected on MRI one year after SBRT. These data highlight the protracted nature of radiographic tumor response to radiation therapy, even with ablative radiation techniques. The analysis is limited by the lack of biopsy data to quantify whether visualized residual tumor harbor active cancer.

Background: Total ankle arthroplasty and arthrodesis are the two mainstreams of treatment for end-stage ankle arthritis. This study was performed to determine which is a better choice for ankle arthritis, using a decision analysis and Markov model to reflect the repetitive nature of revision arthroplasty.Methods: Based on current published evidence, a decision tree was constructed to compare the clinical outcomes of total ankle arthroplasty and arthrodesis, which contained the possible clinical events and the probabilities. Total ankle arthroplasty was subject to revision arthroplasty, and a Markov model was adopted for this branch to reflect this repetitive trait of the procedure. Arthrodesis could cause adjacent arthritis, and a conventional decision analysis model was adopted for this branch. Quality well-being index score was used for clinical outcome assessment, which was the utility in the decision tree. Sensitivity analysis was performed to test the stability of the decision tree and the threshold values.Results: The model favoured total ankle arthroplasty over arthrodesis in terms of quality well-being index score. Sensitivity analysis showed that the model was considerably stable, unaffected by the changes in probabilities of failure after total ankle arthroplasty and adjacent arthritis after arthrodesis.Conclusions: Based on current evidence, total ankle arthroplasty was found to be a better treatment than arthrodesis for ankle arthritis. Future development in the implant materials, improved understanding of ankle biomechanics, and surgical techniques will further enhance the clinical outcome of total ankle arthroplasty. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare the surgical outcomes between bioabsorbable and metal screw fixation for distal tibial physeal fracture in children and adolescents, radiographically and clinically., Methods: This study included consecutive 67 children and adolescents who underwent open reduction and internal fixation using metal or bioabsorbable screws for the distal tibia physeal fracture. All patients underwent preoperative radiographs, three-dimensional computed tomography scans, and postoperative follow-up teleradiogram. Patients were divided into metal (N = 40) and bioabsorbable groups (N = 27). We compared the surgical outcomes between the two groups in terms of clinical and radiographic outcomes, length of hospital stays, and medical cost., Results: Follow-up duration were significantly longer in the metal group than that in the bioabsorbable group. There was no significant difference in the incidence of growth arrest after surgery and the scores of the Oxford Ankle and Foot Questionnaire between the two groups. However, the total hospital stay was significantly longer in the metal group (5.2 ± 4.8 days) compared to the bioabsorbable group (2.6 ± 0.5 days). Medical costs were significantly higher in the bioabsorbable group than in the metal group with a difference of 397 US dollars., Conclusions: The use of bioabsorbable screws exhibited therapeutic effects equivalent to that of metal screws for pediatric distal tibia physeal fractures regarding clinical and radiological outcomes. Moreover, it had the advantage of avoiding the need for repeated general anesthesia and secondary operation for implant removal. Therefore, the use of bioabsorbable screws may be a favourable surgical option for treating pediatric fractures., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

This study aimed to investigate the outcomes of Gamma3 nails fitted with U-blade lag screws in the management of combined neck and trochanter fracture of the femur. Two hundred-fifty patients with fractures in the proximal femur underwent treatment using Gamma3 nails integrated with U-blade lag screws from 2015 to 2022. Among these cases, 33 had combined neck and trochanteric fractures; 8 patients were excluded because of follow-up for <1 year. The remaining data of 25 patients (7 males and 18 females) were reviewed. Bone mineral density (BMD), body mass index (BMI), tip-apex distance (TAD), extent of lag screw migration, femoral neck-shaft angle, callus formation, fracture type, and treatment failure were analyzed. The mean patient age was 76.3 (range, 61-91) years, and the mean follow-up duration was 17.3 (range, 12.5-57.3) months. The mean BMD T-scores for the spine and femoral neck were -2.3 ± 1.0 and -2.8 ± 0.7, respectively; 18 patients had T-scores ≤-2.5, indicating osteoporosis. The mean BMI was 23.2 ± 3.8 kg/m2 , and the mean operative time was 69.8 (range, 45-90) minutes. Twenty-one patients experienced injuries from slipping, 2 sustained injuries from falling, and 2 from car traffic accidents. The mean TAD was 21.6 ± 5.9 mm, with 16 patients showing <25 mm. The mean extent of lag screw migration was 5.7 ± 5.1 mm. The mean femoral neck-shaft angle on plain radiographs was 125.1 ± 8.6 degrees immediately postoperatively and 120.3 ± 9.5 degrees at the final follow-up. During the follow-up period, the first callus formation was observed at 3.8 months (range, 1.4-7.3) on plain radiographs in the anteroposterior and axial views. Based on our fracture criteria, 4 patients had a two-part fracture type, 12 patients had three-part, and 9 patients had four-part. Out of 25 patients, 3 exhibited treatment failure. No significant differences were observed between the groups with and without bone union regarding age, BMD, BMI, operative time, TAD of the lag screw, extent of lag screw migration, and femoral neck-shaft angle. The bone union was achieved in 88% of patients who underwent treatment utilizing the U-blade Gamma3 nail for concomitant ipsilateral neck and trochanteric fractures. Level IV, Therapeutic Study.

Background: This study aimed to demonstrate the occurrence of lower extremity deformities and their risk factors in patients with solitary osteochondromas., Methods: We retrospectively reviewed consecutive patients with solitary osteochondromas around the knee. The laterality (left or right), involved bone (femur or tibia), tumor type (pedunculated or sessile), and direction (medial or lateral) were examined. The whole limb length (WLL), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA) were measured using teleroentgenogram. Lower limb deformity was defined as a difference of more than 5° in mLDFA or MPTA in both lower extremities or a difference in WLL of more than 1 cm. Patients were divided into two groups, with deformity and without deformity., Results: Lower extremity deformities were observed in 8 of 83 patients. Significant difference in the type of osteochondroma (p = 0.004) between the groups was observed. Differences in sex, age, laterality, involved bone, direction, and distance from the physis to the osteochondroma between groups were not statistically significant. The sessile type of osteochondroma was a risk factor for lower limb deformity with an odds ratio of 24.0 according to Firth's logistic regression analysis., Conclusion: In our cohort with solitary osteochondroma, lower limb deformities were observed in 8 (9.6%) out of the 83 patients and these were significantly associated with sessile-type tumors. Therefore, patients with sessile-type solitary osteochondroma around the knee require careful surveillance of lower limb alignment with whole leg teleroentgenogram., (© 2024. The Author(s).)

Background: The rotational change after using a flexible intramedullary (IM) nail for femoral shaft fractures has been a concern for many surgeons. Recently, a statistical shape model (SSM) was developed for the three-dimensional reconstruction of the femur from two-dimensional plain radiographs. In this study, we measured postoperative femoral anteversion (FAV) in patients diagnosed with femoral shaft fractures who were treated with flexible IM nails and investigated age-related changes in FAV using the SSM., Methods: This study used radiographic data collected from six regional tertiary centers specializing in pediatric trauma in South Korea. Patients diagnosed with femoral shaft fractures between September 2002 and June 2020 and patients aged < 18 years with at least two anteroposterior (AP) and lateral (LAT) femur plain radiographs obtained at least three months apart were included. A linear mixed model (LMM) was used for statistical analysis., Results: Overall, 72 patients were included in the study. The average patient age was 7.6 years and the average follow-up duration was 6.8 years. The average FAV of immediate postoperative images was 27.5 ± 11.5°. Out of 72 patients, 52 patients (72.2%) showed immediate postoperative FAV greater than 20°. The average FAV in patients with initial FAV > 20° was 32.74°, and the LMM showed that FAV decreased by 2.5° (p = 0.0001) with each 1-year increase from the time of initial trauma., Conclusions: This study explored changes in FAV after femoral shaft fracture using a newly developed technology that allows 3D reconstruction from uncalibrated 2D images. There was a pattern of change on the rotation of the femur after initial fixation, with a 2.5° decrease of FAV per year., (© 2024. The Author(s).)

Background: This study aimed to translate and transculturally adapt the English version of the Pedi-IKDC questionnaire into Korean and evaluate the psychometric properties of the Korean Pedi-IKDC questionnaire in terms of internal consistency, feasibility (floor and ceiling effect), construct validity, test-retest reliability, and factor analysis., Methods: The original English version of the Pedi-IKDC questionnaire was translated and transculturally adapted into Korean according to established guidelines. A total of 239 patients aged 7-18 years who visited the hospital because of knee pain or discomfort were considered eligible for the study. These patients completed the Korean version of the Pedi-IKDC and Pediatric Quality of Life questionnaires (PedsQL). The correlation between the PedsQL and Pedi-IKDC questionnaires was assessed to confirm the validity of the questionnaire. To verify the validity of the Korean Pedi-IKDC questionnaire, internal consistency, feasibility, test-retest reliability, and construct validity were evaluated, and a factor analysis was performed., Results: Internal consistency was found to be satisfactory in all subscales (Cronbach's alpha ≥ 0.7). The test-retest reliability was satisfactorily high for all subscales (Intraclass correlation coefficient: 0.81-0.84). A high correlation was observed between the total Pedi-IKDC score and the score on the physical-health subscale of child version of the PedsQL (Correlation coefficients: 0.720). There were no floor effects in all subscales, but ceiling effects were observed in four questions. Additionally, factor analysis suggested that the questionnaire could be divided into two subscales., Conclusion: The Korean version of the Pedi-IKDC questionnaire was successfully translated and transculturally adapted according to the established guidelines. The Korean Pedi-IKDC questionnaire has been proven reliable and valid., (© 2024. The Author(s).)

Background and Objective : There is a paucity of literature comparing unilateral instrumented transforaminal lumbar interbody fusion (UITLIF) with bilateral instrumented TLIF (BITLIF) regarding radiological alignment, including the coronal balance, even though UITLIF might have asymmetric characteristics in the coronal plane. This retrospective study aimed to compare the clinical and long-term radiological outcomes of 1-level UITLIF and BITLIF in lumbar degenerative diseases (LDD) including lumbar spinal stenosis with or without spondylolisthesis (degenerative or spondylolytic). Materials and Methods : Patients who underwent 1-level UITLIF with two rectangular polyetheretherketone (PEEK) cages or BITLIF between November 2009 and June 2016 by four surgeons with ≥5 years of follow-up at a single hospital were included. We compared the clinical and radiological outcomes between the UITLIF and BITLIF. Results : In total, 63 and 111 patients who underwent UITLIF and BITLIF, respectively, were enrolled. The median follow-up was 85.55 months (range: 60-130). The UITLIF group had a significantly shorter operation time (185.0 [170.0-210.0] vs. 225.0 [200.0-265.0], p < 0.001) and lower estimated blood loss (300.0 [250.0-500.0] vs. 550.0 [400.0-800.0], p < 0.001) than the BITLIF group. Regarding the clinical outcomes, there were no significant differences in the intermittent claudication score ( p = 0.495) and Kirkaldy-Willis criteria ( p = 0.707) at 1 year postoperatively. The interval changes in the local coronal Cobb angle at the index level, L1-S1 lordotic angle, and coronal off-balance from the immediate postoperative radiograph to the last follow-up were not significantly different ( p = 0.687, p = 0.701, and p = 0.367, respectively). Conclusions : UITLIF with two rectangular PEEK cages may provide comparable clinical outcomes and radiological longevity including coronal alignment to BITLIF in 1-level LDD. In addition, UITLIF has advantages over BITLIF in terms of operative time and blood loss.

Background: Supracondylar humerus (SCH) fractures in children have been traditionally categorized according to the Wilkins-modified Gartland classification scheme, which is solely based on the degree of displacement. As this classification does not consider fracture patterns in the coronal or sagittal plane, the relationship between the fracture pattern and prognosis in SCH fractures remains unclear. Therefore, the purpose of this study was to evaluate the relationship between the fracture level and prognosis of pediatric SCH fractures., Methods: Medical records and radiographs of 786 patients with SCH fractures who underwent surgical treatment between March 2004 and December 2017 were reviewed. A total of 192 patients were included in this study. Anteroposterior elbow radiographs taken at the time of injury were evaluated to obtain the level of fracture. Functional outcomes were evaluated based on modified Flynn grading at the last follow-up., Results: Of 192 patients included in this study, 24 (12.1%), 148 (74.8%), and 20 (10.1%) had fractures in zone 1 (metaphyseal-diaphyseal area), zone 2 (between zones 1 and 3), and zone 3 (metaphyseal-epiphyseal area), respectively. There were significant differences in age at the time of injury ( p = 0.011), direction of fracture displacement ( p = 0.014), and loss of carrying angle ( p < 0.001) between fractures in zone 3 and those in zone 1 or zone 2. Zone 3 fractures and classic zone 2 fractures also showed significant difference in outcomes, with zone 3 fractures having more unsatisfactory outcome than classic zone 2 fractures ( p = 0.049)., Conclusions: For SCH fractures, varus deformity of the elbow was more common in zone 3 (metaphyseal-epiphyseal area) than in the other zones. Thus, pediatric orthopedic surgeons should be mindful of the possibility of cubitus varus deformity when treating SCH fractures in zone 3. A thorough postoperative follow-up is required., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2023 by The Korean Orthopaedic Association.)

Background: Patellar instability is a common knee pathology in skeletally immature patients. In skeletally mature populations, a tibial tubercle-trochlear groove (TT-TG) distance of ≥20 mm is generally considered a pathological value. However, as pediatric patients grow and as the TT-TG distance varies with age, applying the same cutoff value as adult patients to them is unreasonable., Purpose/hypothesis: This study aimed to analyze the normative values of the TT-TG and tibial tubercle-posterior cruciate ligament (TT-PCL) distances in children with no patellofemoral instability and to propose the cutoff value of the TT-TG and TT-PCL distances predictive of increased risk of patellofemoral instability in pediatric patients. We hypothesized that the TT-TG and TT-PCL distances increase with age in children and adolescents., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Magnetic resonance imaging scans of the knee were collected from the patellar instability group and the control group. The TT-TG and TT-PCL distances were measured. The normalized values of the TT-TG and TT-PCL distances were calculated by dividing them by the femoral width. Segmented analysis with 1 breakpoint was performed for both the TT-TG and the TT-PCL distances. The optimal cutoff values of the TT-TG and TT-PCL distances were calculated by maximizing the sum of the sensitivity and specificity., Results: A total of 87 patients had patellar instability, and 509 patients did not. The median values of TT-TG and TT-PCL distances in the control group (8.18 mm and 19.48 mm, respectively) were significantly smaller than those in the instability group (16.10 mm and 24.41 mm, respectively). For those aged <15 years, the TT-TG distance significantly increased by 0.39 mm as the age increased by 1 year. The TT-PCL distance increased by 1.14 mm/year until the age of 11 years. In our cohort, the cutoff value of the TT-TG distance of 14.90 mm yielded 66% sensitivity and 81.9% specificity for predicting an increased risk of patellar instability. The cutoff value of the TT-PCL distance of 23.68 mm yielded 63.9% sensitivity and 65.3% specificity for predicting an increased risk of patellar instability., Conclusion: In our cohort of 596 participants, we have documented the normative values of the TT-TG and TT-PCL distances in children aged <20 years. During the surgery for patellar instability in pediatric patients, orthopaedic surgeons should consider the normative values of the TT-TG and TT-PCL distances according to age to determine which patients need distal realignment surgery.

Background: This study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images., Methods: All patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated., Results: A total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9-34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0-10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1-30.8%). The minimum ratio was 15.1%., Conclusion: A percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury., (© 2023. The Author(s).)

Background: This study investigated the epidemiology and demographics of slipped capital femoral epiphysis (SCFE) in South Korea using a nationwide population-based database., Methods: Information on sex, age at onset, endocrine comorbidities, history of growth hormone therapy, history of radiation therapy, surgical methods, and complications in patients with SCFE aged younger than 18 years between 2007 and 2019 was retrieved from the Korean Health Insurance Review and Assessment Service database., Results: Data were available for 586 children (429 boys, 157 girls). The average age at onset was 11.1 ± 1.8 years (boys, 11.3 ± 1.9; girls, 10.6 ± 1.5). Five hundred and twenty-nine (90.3%) patients were aged 9-14 years; the incidence rate in this age group was 6.0/100,000 (95% confidence interval, 5.5-6.6) and significantly higher in boys (8.4 vs 3.5, p<0.001). There was a significant increase in the annual incidence rate from 0.96/100,000 in 2009 to 2.05/100,000 in 2019 (p = 0.006). Ninety-five patients (16.2%) had endocrine comorbidities or a history of hormone/radiation therapy. Osteotomy and internal fixation were performed in 59 patients and in situ pinning in 527. Seventy-six patients developed postoperative complications., Conclusion: The annual incidence rate of SCFE in South Korea has increased since 2009., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: The objectives of this study were to assess the utility of dynamic contrast-enhanced magnetic resonance (MR) imaging in quantifying parenchymal perfusional changes after embolization and to characterize the association between pharmacokinetic (PK) parameters and final microwave ablation volume., Materials and Methods: PK parameters from dynamic contrast-enhanced MR imaging were used to quantify perfusional changes in the liver after transarterial embolization of the right or left lobe in a swine liver model (n = 5). Each animal subject subsequently underwent microwave ablation (60 W for 5 minutes) of the embolized and nonembolized liver lobes. Changes in PK parameters from dynamic contrast-enhanced MR imaging were correlated with their respective final microwave ablation volumes in each liver lobe., Results: Microwave ablation volumes of embolized liver lobes were significantly larger than those of nonembolized liver lobes (28.0 mL ± 6.2 vs 15.1 mL ± 5.2, P < .001). PK perfusion parameters were significantly lower in embolized liver lobes than in nonembolized liver lobes (K trans  = 0.69 min -1 ± 0.15 vs 1.52 min -1 ± 0.37, P < .001; k ep  = 0.69 min -1 ± 0.19 vs 1.54 min -1 ± 0.42, P < .001). There was a moderate but significant correlation between normalized k ep and ablation volume, with each unit increase in normalized k ep corresponding to a 9.8-mL decrease in ablation volume (P = .035)., Conclusions: PK-derived parameters from dynamic contrast-enhanced MR imaging can be used to quantify perfusional changes after transarterial embolization and are directly inversely correlated with final ablation volume., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Tibial torsion lacks a single and reliable method for its measurement. While physical examination, computed tomography (CT), and EOS imaging are used complementarily, three-dimensional (3D) CT is the most widely used method for intuitive documentation and visualization. However, concern regarding the associated radiation hazard limits its use in the evaluation of pediatric patients. Moreover, EOS machines are too expensive and too large to be placed in every clinic requiring the measurement of tibial torsion. Therefore, a new method for 3D reconstruction is needed. In the present study, we tested the validity and reliability of a novel reconstruction tool for the lower leg., Methods: A statistical shape model and Laplacian constraint were adopted for the development of a new reconstruction tool for measuring tibial torsion. Tibial torsion measurements based on a 3D reconstruction application and CT images for 36 patients were evaluated for intraobserver and interobserver reliability. Tibial torsion measurements for 75 patients were compared for validation., Results: A 3D reconstruction system for the lower leg was developed as a mobile application and was installed in a portable device for easy access in the clinical setting. In terms of interobserver reliability, the intraclass correlation coefficient among 3 clinicians was 0.896 (95% confidence interval [CI], 0.828 to 0.941). The correlation coefficient between tibial torsion measured with use of 3D CT and that measured with the mobile application was 0.865 (p < 0.001)., Conclusions: The mobile application showed excellent reliability and validity for measuring tibial torsion. Concurrent utilization with mobile application for the femur allows visualization of the rotational profile of the leg without the need for CT or EOS., Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H246 )., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Competing Interests: Declaration of Competing Interest This study was supported by the SNUBH research fund (Grant No. 02-2018-037) and Korea Institute of Planning and Evaluation for Technology in Food, Agriculture, Forestry and Fisheries (IPET) through High Value-added Food Technology Development Program, funded by Ministry of Agriculture, Food and Rural Affairs (MAFRA) (117051-3). No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article. We have full control of all primary data and we agree to allow the journal to review our data.

Objective: We aimed to investigate if the use of read-out segmented echoplanar imaging with additional two-dimensional navigator correction (Readout Segmentation of Long Variable Echo, RESOLVE) for acquiring prostate diffusion-weighted imaging (DWI) improves image quality, compared to single-shot echoplanar imaging (ss-EPI)., Methods: This single-center prospective study cohort included 162 males with suspected prostate cancer, who underwent 3 Tesla multiparametric MRI (3T-mpMRI). Two abdominal radiologists, blinded to the clinical information, separately reviewed each 3T-mpMRI study to rank geometrical distortion, degree of rectal distention, lesion conspicuity, and anatomic details delineation first on ss-EPI-DWI and later on RESOLVE-DWI using 5-point scales (1 = excellent, 5 = poor). The average of the ranking scores given by two readers was generated and used as the final score., Results: There was good-to-excellent interreader agreement for scoring image quality parameters on both ss-EPI and RESOLVE. Geometrical distortion scores > 3 was seen in 12.3% (20/162) of ss-EPI images, with all having geometrical distortion score <3 on RESOLVE ( p < .001). The mean image distortion score was significantly less on RESOLVE than ss-EPI (1.16 vs 1.61, p < .01 regardless of rectal gas, p< .05 when stratified by the degree of rectal distention ). RESOLVE was superior to ss-EPI for lesion conspicuity (mean 1.35 vs 1.53, p< .002) and anatomic delineation (2.60 vs 2.68, p< .001) of prostate on DWI., Conclusion: Compared to conventional ss-EPI, the use of RESOLVE for acquisition of prostate DWI resulted in significantly enhanced image quality and reduced geometrical distortion., Advances in Knowledge: RESOLVE could be an alternative or replacement of ss-EPI for acquiring prostate DWI with significantly less geometrical distortion and significantly improved lesion conspicuity and anatomic delineation.

Background: This study was performed to evaluate the rebound phenomenon after the correction of coronal angular deformity by hemiepiphysiodesis using tension band plate in children and to identify its risk factors., Methods: We reviewed 50 children (mean age, 11.0 ± 2.5 years) with 94 physes who had undergone hemiepiphysiodesis using tension band plate due to coronal angular deformity of the lower limb. Patients' demographic data including sex, age at initial surgery and plate removal, affected bone (distal femur or proximal tibia), affected side, and body mass index were collected. The mechanical lateral distal femoral angle (mLDFA) and the mechanical medial proximal tibial angle (mMPTA) were measured from the teleradiogram, Physes were divided into rebound and non-rebound group, and rebound group was defined as the physes which had  ≥  5° of mLDFA or mMPTA returning to its original deformity. Generalized estimating equation based multivariable analysis was used to identify the risk factors for the rebound phenomenon after the deformity correction., Results: A total of 41 physes classified into rebound group and 53 physes into non-rebound group. There were significant differences in the age at initial surgery (p = 0.004), the age at implant removal (p = 0.002), the amount of correction (p = 0.001), and the rate of correction (p < 0.001) between two groups. The rate of correction was significantly associated with the rebound phenomenon (p = 0.044). The risk of rebound phenomenon was 1.2-fold higher as the rate of correction increased by 1° per year. The cutoff values of the correction rate between the two groups were 6.9°/year (p < 0.001)., Conclusions: This study showed that the rebound group had younger age and faster correction rate than those in the non-rebound group. In addition, the correction rate for deformity was a significant risk factor for the rebound phenomenon after hemiepiphysiodesis using the tension band plate. Close monitoring after implant removal is required for children who have a rapid correction rate over 7°/year., (© 2022. The Author(s).)

Background: Breech presentation is one of the most important risk factors for developmental dysplasia of the hip, and all breech infants should be screened. The necessity of further follow-up of developmental dysplasia of the hip after normal clinical and sonographic screening is a controversial subject. The purpose of this study to identify the incidence of delayed dysplasia in breech infants after normal ultrasound screening and the necessity of further clinical and radiologic follow-up in these patients., Methods: We included the 292 breech babies (128 boys and 164 girls) who showed normal hip ultrasound screening results. To determine the incidence of delayed radiographic dysplasia, anteroposterior hip radiographs were taken between 12 and 24 months of age to measure the acetabular index (AI)., Results: The mean AI values were 22.8±3.4 in boys and 24.9±3.1 in girls. Applying the Tönnis criteria, 29 patients (9.9%) were considered to have delayed radiographic dysplasia (16 boys and 13 girls). No significant difference was found in any demographic variables between babies with and without delayed radiographic dysplasia. None of these 29 infants underwent any treatment for radiographic dysplasia. Applying Kuong's criteria to 292 infants, only 2 patients (0.7%) demonstrated radiographic dysplasia on the hip anteroposterior radiographs taken at 14 months., Conclusions: The incidence of radiographic dysplasia significantly varied depending on which criteria were applied. In order to find out more accurate incidence rates of delayed radiographic dysplasia, large-scale studies of the normative AI data for Korean infants are required., Level of Evidence: Prognostic Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

We aimed to investigate the progression of patella alta (PA) in patients with cerebral palsy (CP) using the Koshino-Sugimoto (KS) index and assess associated risk factors. Participants in our retrospective study met the following inclusion criteria: patients with CP who visited our institute from May 2003 to December 2019, were ≤18 years of age, were followed up for >2 years and had at least two lateral knee radiographs. KS indices of both knee radiographs were measured for each patient. A linear mixed model was implemented. Our participants included 222 CP patients. KS index values were measured via 652 knee radiographs. Reference values of the KS index for those between 4 and 18 years of age were determined according to Gross Motor Function Classification System (GMFCS) levels. In all GMFCS levels, the KS index decreased with patients' ages (P < 0.0001). In groups where the KS index increased, GMFCS levels IV (P = 0.0045) and V (P = 0.0040) were statistically significant. Change in the KS index values indicates that PA improves as patients age within all GMFCS levels. However, in patients with GMFCS levels of IV and V, progressive PA is expected., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to investigate the usefulness of bone single-positron emission tomography/computed tomography (SPECT/CT) of the hip in predicting the later occurrence of avascular necrosis (AVN) after slipped capital femoral epiphysis (SCFE) or femoral neck fracture in pediatric patients. The quantitative parameters of SPECT/CT useful in predicting AVN were identified., Materials and Methods: Twenty-one (male:female, 10:11) consecutive patients aged < 18 years (mean age ± standard deviation [SD], 11.0 ± 2.7 years) who underwent surgery for SCFE or femoral neck fracture and postoperative bone SPECT/CT were included. The maximum standardized uptake value (SUV), mean SUV, and minimum SUV of the femoral head were measured. The ratios of the maximum SUV, mean SUV, and minimum SUV of the affected femoral head to the contralateral side were determined. Patients were followed up for > 1 year after the surgery. The SPECT/CT parameters were compared between patients who developed AVN and those who did not. The accuracy of SPECT/CT parameters for predicting AVN was assessed., Results: Six patients developed AVN. There was a significant difference in the ratio of the mean SUV among patients who developed AVN (mean ± SD, 0.8 ± 0.3) and those who did not (1.1 ± 0.2, p = 0.018). However, there were no significant differences in the ratios of the maximum and minimum SUV between the groups (all p = 0.205). For the maximum, mean, and minimum SUVs, no significant differences were observed between the groups ( p = 0.519, 0.733, and 0.470, respectively). The cutoff mean SUV ratio of 0.87 yielded a 66.7% sensitivity and 93.2% specificity for predicting AVN., Conclusion: Quantitative bone SPECT/CT is useful for evaluating femoral head viability in pediatric patients with SCFE or femoral neck fractures. Clinicians should consider the high possibility of later AVN development in patients with a decreased mean SUV ratio., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2022 The Korean Society of Radiology.)

Purpose: This study evaluated the rates and annual trends of pediatric CT scans in South Korea using a nationwide population-based database., Materials and Methods: Data regarding pediatric CT scan usage between 2012 and 2017 were retrieved from the health insurance review and assessment service. Data on the age, sex, diagnosis, and the anatomical area of involved patients were also extracted., Results: A total of 576376 CT examinations were performed among 58527528 children aged below 18 years (9.8 scans/1000 children), and the number of CT examinations per 1000 children was noted to have increased by 23.2% from 9.0 in 2012 to 11.0 in 2017. Specifically, the number of CT examinations increased by 32.9% for the 6-12 years of age group (7.4/1000 to 9.8/1000) and by 34.0% for the 13-18 years of age group (11.4/1000 to 15.3/1000). Moreover, majority of the CT scans were limited to the head (39.1%), followed by the extremities (32.5%) and the abdomen (13.7%). Notably, the number of extremity CT scans increased by 83.6% (2.3/1000 to 4.2/1000), and its proportion as compared to other scans increased from 25.3% to 37.7%., Conclusion: CT scans in the pediatric population increased continuously from 2012 to 2017 at an annual rate of 4.4%. Therefore, physicians should balance the benefits of CT with its potential harms from associated radiation exposure in pediatric patients., Competing Interests: Conflicts of Interest: The authors have no potential conflicts of interest to disclose., (Copyrights © 2022 The Korean Society of Radiology.)

This study was to analyze intrasubject radiographic progression of the hallux valgus deformity by comparing the mildly and severely affected sides in patients with bilateral asymmetric hallux valgus in the whole group as well as the metatarsus adductus and the nonmetatarsus adductus subgroups. A total of 186 patients with bilateral asymmetrical hallux valgus deformity with a difference of 5° or greater in the hallux valgus angle were included, and 11 radiographic measurements were analyzed. The radiographic differences between the mildly and severely affected sides were compared. Correlation between the changes in the hallux valgus angle and those in other measurements was analyzed, and multiple regression analyses were performed. The anteroposterior talo-second metatarsal angle showed no significant difference between the mildly and severely affected sides. Changes in the intermetatarsal angle and sesamoid rotation angle were significantly associated with the progression of hallux valgus angle in the whole group as well as the nonmetatarsus adductus subgroup. Change in the intermetatarsal angle (p = .006) was the significant factor associated with the progression of hallux valgus angle in the metatarsus adductus subgroup. The anteroposterior talo-second metatarsal angle might be useful in evaluating the overall foot shape in the hallux valgus deformity. Progression of the hallux valgus deformity might be pathophysiologically different between those with and without metatarsus adductus., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Abstract: There has been no study evaluating the change of limb alignment for patients with genu valgum. The purpose of this study was to investigate the change of limb alignments in children and adolescents with idiopathic genu valgum through evaluating distal femur, proximal tibia, and knee joint line.Consecutive children and adolescents, under the age of 18, with genu valgum were included. Mechanical tibiofemoral angle, mechanical lateral distal femoral angle, mechanical medial proximal tibia angle, and joint line convergence angle were measured. The rate of changes for each radiographic measurement were analyzed using a linear mixed model.A total of 1539 teleroentgenograms from 518 limbs of 273 individuals were included in this study. Linear mixed model showed that the change of limb alignment was significantly associated with age, but not associated with gender and laterality. The mechanical tibiofemoral angle was most valgus initially, decreasing until reaching its lowest value of 2.8° at 10 years old. The mechanical lateral distal femoral angle decreases from initial neutral alignment and increases in valgus continuously. The mechanical medial proximal tibia angle decreases from initial valgus and progresses to be neutral at around the age of 10. The joint line convergence angle decreases sharply from initial valgus alignment to 0° at the age of 5.Valgus alignment in children with idiopathic genu valgum decreases until approximately the age of 10. In younger children, the tibia and joint line contribute most to overall valgus alignment; in older children, the femur contributes the most. Based on our results, we recommend monitoring patient limb alignment until it stabilizes around the age of 10, and then carefully planning and performing corrective surgery with complete consideration of the changing bony alignment., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: This study investigated the effect of screw configuration on the rate of correction of coronal angular deformity of the knee joint in children who underwent guided growth using the tension-band plate., Methods: Consecutive patients (76 patients with 154 physes; mean age: 11.8±2.2 y) who underwent guided growth using the tension-band plate for coronal angular deformity (genu varum or genu valgum) were included. The mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and screw angle were measured from the teleroentgenograms of preoperative and postoperative periodic follow-up visits., Results: The mean initial screw angle and the mean rate of correction were 16.7±10.5 degrees and 6.5±5.3 degrees per year, respectively. The rate of correction was significantly affected by age at surgery, sex, physis treated, severity of deformity, and rate of change in screw angle (all P<0.001). However, the initial screw angle and type of deformity did not affect the rate of correction. The rate of correction per year was 3.6 degrees higher in boys than in girls and 2.8 degrees higher in the distal femur than in the proximal tibia. A 1 degree increase in the rate of change in screw angle was associated with a 0.5 degree increase in the correction rate. Screw angle significantly increased with follow-up duration (P<0.001) and the change in screw angle was significantly affected by age, sex, and physis treated (all P<0.001)., Conclusions: This study demonstrated that screw configuration did not affect the correction rate of coronal angular deformity for guided growth using the tension-band plate. Therefore, surgeons only need to insert the screws according to anatomic restriction, not considering the screw configuration when using the tension-band plate for guided growth in children., Level of Evidence: Prognostic level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Backgroud: Single-event multilevel surgery (SEMLS) and hip reconstructive surgery (HRS) often cause intraoperative bleeding, consequently increasing the probability of transfusion and postoperative laboratory changes. Therefore, it is important to assess risk factors to predict the amount of blood loss. This study aimed to evaluate blood loss, its influencing factors, and the related laboratory changes during SEMLS and HRS in patients with cerebral palsy (CP)., Methods: We retrospectively examined consecutive CP patients who underwent SEMLS and HRS. Surrogate markers of blood loss, including preoperative and postoperative hemoglobin (Hb), hematocrit, and changes in Hb concentration, were assessed. Albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatine levels were also analyzed for related laboratory changes. Risk factors were analyzed using multiple regression and logistic regression models., Results: The overall cohort comprised 1,188 patients. Of them, 1,007 and 181 underwent SEMLS and HRS, respectively. Furthermore, 72 of 181 patients underwent a concomitant Dega osteotomy. The regression model showed that low preoperative Hb concentration ( p < 0.001), high albumin level ( p = 0.007), low body mass index (BMI) ( p = 0.002), and bilateral HRS ( p < 0.001) were significant risk factors of postoperative anemia. Valproate medication was associated with Hb drop, and the risk factors for Hb level < 8 g/dL on postoperative day 2 were bilateral HRS and Dega osteotomy in the HRS subgroup. In total, 21.6% had elevated AST levels on postoperative day 2, and bilateral HRS ( p < 0.001), Gross Motor Function Classification System (GMFCS) level V ( p = 0.041), Dega osteotomy ( p < 0.001), and high preoperative AST level ( p < 0.001) increased the risk of AST elevation., Conclusions: We have summarized the estimated blood loss and related laboratory changes after SEMLS and HRS in patients with CP and identified the risk factors. Clinical guidelines should be accordingly developed to include assessment of these risk factors and their impact in the outcomes of CP patients undergoing SEMLS and HRS., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2021 by The Korean Orthopaedic Association.)

We report the case of a pediatric patient with Ewing's sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.

Abstract: Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors.We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects.We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P < .001), talonavicular coverage angle (P < .001), and lateral talo-first metatarsal angle (P < .001) improved significantly; however, the calcaneal pitch angle (P = .367) did not show any significant difference. In general, the flatfeet showed an improving trend; after analyzing the factors, no sex difference was observed (P = .117), while body mass index (P < .001) and Achilles tendon contracture (P < .001) showed a negative correlation.The study demonstrated that children's flatfeet spontaneously improved at the age of 12 years. It would be more beneficial if the clinician shows the predicted appearance of the foot at the completion of growth by calculating the radiographic indices and identifying the correlating factors in addition to explaining that flatfoot may gradually improve. This will prevent unnecessary medical expenses and the psychological adverse effects to the children caused by unnecessary treatment., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Gait deviation and associated torsional problems are common in patients with cerebral palsy (CP). Although femoral anteversion in CP has been extensively reviewed in previous studies, only a few studies have focused on tibial torsion. Therefore, this study aimed to evaluate tibial torsion in patients with CP and investigate the affecting factors., Methods: Consecutive patients with cerebral palsy who underwent 3-dimensional computed tomography for the assessment of rotational profiles were reviewed. Femoral anteversion and tibial torsion were measured, and the demographic characteristics of the patients were recorded. A linear mixed model was implemented to overcome the retrospective nature of the study., Results: After the implementation of inclusion and exclusion criteria, 472 patients were enrolled for this study. With age, external tibial torsion increased, while femoral anteversion decreased. The factors affecting external tibial torsion were increased femoral anteversion (p = 0.0057), increased age (p < 0.0001), higher Gross Motor Function Classification System (GMFCS) level (p < 0.0001), and involved/uninvolved limbs of hemiplegia (p = 0.0471/p = 0.0047)., Conclusions: Older age, GMFCS level IV/V, hemiplegia, and increased femoral anteversion were the independent risk factors of increased external tibial torsion; therefore, performing an imaging study is recommended for assessing the extent of tibial torsion in patients with such characteristics., (© 2021. The Author(s).)

This retrospective study was conducted to investigate the correlation between kinetic gait parameters and femoral bone mineral density (BMD) in elderly subjects aged 50 years and older that could walk independently. Four hundred and twenty-six subjects (158 men and 258 women; mean age 68.7 years, standard deviation (SD) 7.9 years) were included in the study. BMDs (g/cm 2 ) of the femoral neck, trochanter, shaft, and total proximal femur were collected. Kinetic data including maximum hip power and hip power-time integral was obtained from a three-dimensional gait analysis with self-selected walking speed. Correlation between BMDs of proximal femur and gait kinetic data was analyzed. Multiple regression analysis was also performed to identify factors significantly associated with BMD. Correlation between BMD and hip kinetic data was not prominent in elderly men. In women, BMD was significantly correlated with hip kinetic data. Hip power-time integral showed greater correlation with BMD than maximum hip power during gait in elderly women. Age (p < 0.001), weight (p = 0.007) and hip power-time integral (p = 0.008) were significant factors associated with femoral neck BMD, and these factors explained 25.4% of femoral neck BMD. In conclusion, the association between the mechanical load and BMD in the different sexes provokes future research into these issues. The effects of various types of exercises on BMD should be investigated more precisely using a gait analysis tool., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: This study was performed to investigate leg-length discrepancy (LLD) and associated risk factors after paediatric femur shaft fractures., Methods: A total of 72 consecutive patients under 13 years old (mean age 6.7 years; 48 boys, 24 girls) with unilateral femur shaft fracture, and a minimum follow-up of 18 months, were included. The amount of LLD was calculated by subtracting the length of the uninjured from that of the injured limb. Risk factors for an LLD ≥ 1 cm and ≥ 2 cm were analyzed using multivariable logistic regression analysis., Results: Hip spica casting, titanium elastic nailing and plating were performed on 22, 40 and ten patients, respectively. The mean LLD was 7.8 mm (sd 8.8) and 29 (40.3%) had a LLD of ≥ 1 cm, while nine (12.5%) had a LLD of ≥ 2 cm. There were significant differences in fracture stability (p = 0.005) and treatment methods (p = 0.011) between patients with LLD < 1 cm and ≥ 1 cm. There were significant differences in fracture site shortening (p < 0.001) and LLD (p < 0.001) between patients with length-stable and length-unstable fractures. Fracture stability was the only factor associated with LLD ≥ 1 cm (odds ratio of 4.0; p = 0.020) in the multivariable analysis., Conclusion: This study demonstrated that fracture stability was significantly associated with LLD after paediatric femur shaft fractures. Therefore, the surgeon should consider the possibility of LLD after length-stable femur shaft fracture in children., Level of Evidence: Prognostic level III., (Copyright © 2021, The author(s).)

Background: Ankle stress radiographs are important tools for evaluating chronic lateral ankle instability. The consistency of a patient's ankle condition as it affects the reliability of ankle stress radiographs has never been evaluated., Purpose: To investigate the consistency and reliability of ankle stress radiographs in patients with chronic lateral ankle instability without an ankle injury during the study period., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Included were patients with chronic lateral ankle instability who underwent 2 repeated ankle stress radiographs between January 2014 and July 2019; those with an ankle injury during the study period were excluded. The tibiotalar tilt angle on varus stress radiographs and anterior translation of the talus on anterior drawer stress radiographs were measured at initial presentation and final follow-up examination. Interobserver reliability and consistency of ankle stress radiographs were analyzed using the intraclass correlation coefficient (ICC)., Results: A total of 45 patients (mean ± standard deviation age, 36.4 ± 13.4 years; 18 men and 27 women; follow-up duration, 9.1 ± 3.2 months) were included. The mean ± standard deviation tibiotalar tilt angle and anterior talar translation at initial presentation were 10.8° ± 5.2° and 6.9 ± 2.7 mm, respectively. The interobserver reliabilities of the tibiotalar tilt angle and anterior talar translation were excellent (ICC = 0.926 [95% CI, 0.874-0.959] and 0.911 [95% CI, 0.766-0.961], respectively). The consistency between the initial and final radiographs was good for tibiotalar tilt angle (ICC = 0.763 [95% CI, 0.607-0.862]) and poor for anterior talar translation (ICC = 0.456 [95% CI, 0.187-0.660])., Conclusion: Although the interobserver reliability of the radiographic measurements was excellent, the consistency of the ankle stress radiographs was not as acceptable. Surgeons need to be cautious when deciding whether to operate on a patient with chronic lateral ankle instability based on a single ankle stress radiograph., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by the Bio & Medical Technology Development Program of the National Research Foundation (NRF) funded by the Ministry of Science & ICT (NRF-2017M3A9D8064200) and Seoul National University Bundang Hospital Research Fund (grant No. 13-2018-019). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: In a randomized controlled trial, we compared the bone mineral densities (BMDs) and blood markers of bone turnover during short-term treatment of osteoporotic women with bisphosphonate alendronate or bazedoxifene, a selective estrogen receptor modulator., Methods: Ten and eleven patients were randomized to the alendronate and bazedoxifene groups, respectively. BMDs were measured before and after 6 months of treatment. Blood tests were used to measure the levels of osteocalcin (OC), C-terminal telopeptide of type I collagen (CTX), vitamin D3, and parathyroid hormone pretreatment and after 3 and 6 months of treatment. The variables were compared statistically., Results: The alendronate group showed decreases in blood levels of both OC and CTX during the study period (P<0.001 and P=0.002, respectively), while the bazedoxifene group had a decrease only in OC levels (P=0.012). After 6 months of treatment, BMDs significantly increased in the alendronate group at multiple bone sites, including the L1-4 lumbar vertebrae, femur trochanter, and total femur. However, there was no significant increase in BMD in the bazedoxifene group. BMDs were not significantly different between the 2 groups., Conclusions: Patients treated with alendronate showed more rapid suppression of markers of bone turnover and higher BMD than those treated with bazedoxifene during a short-term regime. Considering the effects and complications of each medication, the relationship between bone turnover rate and bone quality will need to be investigated in future studies.

Background: . This study performed to investigate the incidence of growth arrest such as leg length discrepancy (LLD) and ankle joint angular deformity and its risk factors after physeal fracture of the distal tibia in children and adolescents., Materials and Methods: . Consecutive 78 patients (mean age 11.4 ± 2.0 years; mean follow-up period 2.0 ± 1.2 years) treated for the distal tibia physeal fracture were included. All patients underwent preoperative ankle radiographs, three-dimensional computed tomography (CT) scans, and postoperative follow-up teleradiogram. Patients were divided into two groups according to the LLD and the difference of lateral distal tibial angle (LDTA) with the contralateral limb as follows: Group 1 (growth arrest), patients with LLD ≥ 1cm or difference of LDTA ≥ 5°; Group 2 (normal growth), patients with LLD < 1cm and difference of LDTA < 5°., Results: . The overall incidence of growth arrest was 12.8% (10 of 78). The mean displacement measured using CT scan was 4.4 ± 3.2 mm (range, 0.8-14.9). Of the total 78 fractures, 65 were treated surgically and 13 fractures were treated conservatively. The initial fracture displacement was significantly different between the two groups (p<0.001). However, there were no statistically significant differences between the two groups with respect to other factors. Initial displacement was the only significant risk factor for growth arrest (p<0.003). The cutoff values of initial displacement between the two groups were 5.2mm., Conclusions: . This study showed that degree of initial displacement was the only significant risk factor for growth arrest after physeal fracture of the distal tibia in children and adolescents. Therefore, physicians should consider the possibility of growth arrest for patients with severely displaced physeal fractures of the distal tibia., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest in the preparation of this study., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Although gait disturbances are relatively common symptoms in diabetic polyneuropathy (DPN), few studies have quantitatively analyzed gait and posture in DPN patients. This study aimed to analyze gait and posture quantitatively in DPN patients and to determine the association between clinical and electrophysiological parameters and gait and posture parameters., Methods: Sixty-four DPN patients were enrolled in this study. DPN was clinically assessed using the Toronto clinical neuropathy score (TCNS). All participants underwent nerve conduction study (NCS), three-dimensional motion analysis, and static posturography. We evaluate the correlation of gait and posture parameters with electrophysiological and clinical parameters., Results: Foot height, step length, and stride length among gait parameters were inversely correlated with the TCNS. Anteroposterior range during eyes-closed and mediolateral distance and range during eyes-open and eyes-closed were inversely correlated with the sensory nerve action potential amplitude in the sural nerve. Mediolateral distance during eyes-open and eyes-closed was correlated with the compound muscle action potential amplitude in the peroneal nerve., Conclusions: Gait parameters are associated with clinical parameters, and postural parameters are associated with electrophysiological parameters, particularly sensory NCS. Gait and postural analysis can be a useful tool for assessing the neurological status in DPN patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: This study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures., Materials and Methods: This study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD < 1 cm and ≥ 1 cm and overgrowth < 1 cm and ≥ 1 cm., Results: Casting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p < 0.001) between patients with LLDs < 1 cm and ≥ 1 cm. There were significant differences in sex (p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p < 0.001) between patients with overgrowth < 1 cm and ≥ 1 cm. Sex and treatment methods were risk factors associated with LLD ≥ 1 cm and overgrowth ≥ 1 cm following pediatric tibial shaft fracture. The boys had a 7.4-fold higher risk of LLD ≥ 1 cm and 5.4-fold higher risk of overgrowth ≥ 1 cm than the girls. Patients who underwent TEN had a 4.3-fold higher risk of LLD ≥ 1 cm and 4.8-fold higher risk of overgrowth ≥ 1 cm than those treated by casting., Conclusions: Patients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys., Level of Evidence: Level III.

Background: This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity., Methods: Consecutive 97 patients (150 feet; mean age 10 years; range 5.1-35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model., Results: There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (- 5.0°, p = 0.034) than those with idiopathic cause., Conclusion: This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study's findings when planning operative treatment for such patients.

Aims: Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP., Methods: We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement., Results: A total of 108 patients were enrolled. The mean preoperative MP was 58.3% (SD 31.7%), which improved to 9.1% (SD 15.6%) at the last follow-up. NSA and MHR improved from 156.5° (SD 11.5°) and 82.3% (SD 8.6%) to 126.0° (SD 18.5°) and 89.1% (SD 9.0%), respectively. Factors affecting the postoperative MHR were preoperative MP (p = 0.005), immediate postoperative MP (p = 0.032), and history of Dega osteotomy (p = 0.046)., Conclusion: We found that hip sphericity improves with HRS. Preoperative MP, reduction quality, and acetabular coverage influence femoral head remodelling. We recommend that surgeons should consider intervention early before hip displacement progresses and that during HRS, definite reduction and coverage of the femoral head should be obtained. Cite this article: Bone Joint J 2021;103-B(1):198-203.

Background: Orthopedic physicians typically apply a cast to immobilize a body part that has been injured. There have been no significant structural changes or advances in synthetic casts since the development of the modern cast. The Opencast ® is a recently developed type of cast that allows ventilation and direct visual inspection of the skin to avoid cast-related complications. Although this novel cast appears to have more benefits than the conventional synthetic cast, its clinical efficacy and advantages have not been established., Aim: To investigate the clinical efficacy and advantages of the newly developed Opencast ® based on patients' perspectives in those with ankle inversion injury., Methods: A specifically designed questionnaire consisting of 19 items was used to compare patients' opinions and concerns of the Opencast ® and the conventional synthetic cast. The items were focused on subjective patient satisfaction, discomfort, and adverse effects while wearing the cast. Patients with an ankle inversion injury diagnosed as a high-grade ankle sprain were enrolled. The subjects were randomized and instructed to fill the questionnaire after wearing a synthetic cast or an Opencast ® for 2 wk. They were then required to fill the questionnaire again, after switching to the alternative type of cast for 2 more weeks., Results: A total of 22 subjects participated in the study. The synthetic cast appeared to be more rigid and stable than the Opencast ® , but there was no significant difference in the amount of pain relief. The likelihood of adverse effects when wearing the synthetic cast was significantly higher. Patient satisfaction tended to be rated higher after wearing the Opencast ® . Opencast ® showed more subjective vulnerability than the synthetic cast, but there was no significant difference in the redo rate. Patients were more anxious about removal of the synthetic cast than of the Opencast ® ., Conclusion: The results indicate that the Opencast ® could replace the conventional synthetic cast as it offers increased patient satisfaction, which would in turn increase compliance to treatment., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest regarding this study., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

This study evaluated the shielding effect of a newly developed dose-reduction fiber (DRF) made from barium sulfate, in terms of radiation doses delivered to patients' radiosensitive organs and operator during C-arm fluoroscopy and its impact on the quality of images. A C-arm fluoroscopy unit was placed beside a whole-body phantom. Radiophotoluminescent glass dosimeters were attached to the back and front of the whole-body phantom at 20 cm intervals. Radiation doses were measured without DRF and with it applied to the back (position 1), front (position 2) or both sides (position 3) of the phantom. To investigate the impact of DRF on the quality of fluoroscopic images, step-wedge and modulation transfer function phantoms were used. The absorbed radiation doses to the back of the phantom significantly decreased by 25.3-88.8% after applying DRF to positions 1 and 3. The absorbed radiation doses to the front of the phantom significantly decreased by 55.3-93.6% after applying DRF to positions 2 and 3. The contrast resolution values for each adjacent step area fell in the range 0.0119-0.0209, 0.0128-0.0271, 0.0135-0.0339 and 0.0152-0.0339 without and with DRF applied to positions 1, 2 and 3, respectively. The investigated DRF effectively reduces absorbed radiation doses to patients and operators without decreasing the quality of C-arm fluoroscopic images. Therefore, routine clinical use of the DRF is recommended during the use of C-arm fluoroscopy., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

Background: Idiopathic pes planovalgus is one of the most common foot deformities in children and adolescents. However, there is a discrepancy between subjective symptoms and radiographic severity in idiopathic planovalgus deformity, and very few studies have investigated this aspect. Further, the assessment of subjective symptoms in patients with pes planovalgus requires a quantitative scoring system for making meaningful comparisons, such as the Oxford Ankle Foot Questionnaire for Children (OxAFQ-c) and that for parents (OxAFQ-p). Therefore, the purpose of this study was to evaluate the factors affecting the symptoms of idiopathic planovalgus using the OxAFQ., Methods: All patients who were ≤18 years of age, had visited our clinic for the evaluation of pes planovalgus deformity, and had completed the OxAFQ were included in this study. The anteroposterior talo-first metatarsal, lateral talo-first metatarsal, and hallux valgus angles were measured on weight-bearing radiographs. The data were analyzed using a multiple regression model, with age, sex, and radiographic indices as explanatory variables., Results: Overall, 123 patients were enrolled in this study, and 246 standing foot radiographs were evaluated along with scores in each domain of the OxAFQ. The factors affecting physical domain scores in the OxAFQ-c were female sex (p = 0.047) and the anteroposterior talo-first metatarsal angle (p = 0.033). Age of ≥10 years was a significant factor (p < 0.05) affecting all domains in both the OxAFQ-c and OxAFQ-p other than the physical domain score., Conclusions: Although pes planovalgus deformity is 3-dimensional, the forefoot abduction component of the deformity should be carefully assessed as it is closely related to subjective symptoms. Further, in female patients with a more severe anteroposterior talo-first metatarsal angle, an aggravation of symptoms with aging should be expected when managing pes planovalgus deformity., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The purpose of this study was to identify differences in caregiver responses to Korean-language and English-language versions of the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire., Methods: Patient data were acquired from the Cerebral Palsy Hip Outcomes Project database, which was established to run a large international multicenter prospective cohort study of the outcomes of hip interventions in cerebral palsy. Thirty-three children whose caregivers had completed the Korean version of CPCHILD were matched by propensity scoring with 33 children whose parents completed the English version. Matching was performed on the basis of 12 covariates: age, gender, gross motor function classification system level, migration percentage of right and hip, seizure status, feeding method, tracheostomy status, pelvic obliquity, spinal deformity, parental report of hip pain and contracture interfering with care., Results: There were no significant differences in CPCHILD scores for section 4 (Communication and Social Interaction), and section 5 (Health) between two groups. Korean-language CPCHILD scores were significantly lower than English-language CPCHILD scores for section 1 (Personal Care/Activities of Daily Living), section 2 (Positioning, Transferring and Mobility), section 3 (Comfort and Emotions) and section 6 (Overall Quality of Life) as well as in terms of total score., Conclusions: Cultural influences, and the community or social environment may impact the caregivers' perception of the health-related quality of life of their children. Therefore, physicians should consider these differences when interpreting the study outcomes across different countries.