Publications by authors named "Ki Hyuk Sung"

97 Publications

Intrasubject Radiographic Progression of Hallux Valgus Deformity in Patients With and Without Metatarsus Adductus: Bilateral Asymmetric Hallux Valgus Deformity.

J Foot Ankle Surg 2021 Jun 11. Epub 2021 Jun 11.

Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejon, Korea. Electronic address:

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.
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http://dx.doi.org/10.1053/j.jfas.2020.05.025DOI Listing
June 2021

Leg-length discrepancy and associated risk factors after paediatric femur shaft fracture: a multicentre study.

J Child Orthop 2021 Jun;15(3):215-222

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Korea.

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.
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http://dx.doi.org/10.1302/1863-2548.15.200252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223087PMC
June 2021

Comparison of Bone Mineral Density and Markers of Bone Turnover in Osteoporotic Women after 6-Month Treatment with Alendronate or Bazedoxifene: A Randomized Controlled Trial.

J Bone Metab 2021 May 31;28(2):131-137. Epub 2021 May 31.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

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.
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http://dx.doi.org/10.11005/jbm.2021.28.2.131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206607PMC
May 2021

Consistency and Reliability of Ankle Stress Radiography in Patients With Chronic Lateral Ankle Instability.

Orthop J Sports Med 2021 May 18;9(5):23259671211004099. Epub 2021 May 18.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea.

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.
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http://dx.doi.org/10.1177/23259671211004099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135217PMC
May 2021

Can gait kinetic data predict femoral bone mineral density in elderly men and women aged 50 years and older?

J Biomech 2021 06 12;123:110520. Epub 2021 May 12.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, South Korea. Electronic address:

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) 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.
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http://dx.doi.org/10.1016/j.jbiomech.2021.110520DOI Listing
June 2021

Leg length discrepancy, overgrowth, and associated risk factors after a pediatric tibial shaft fracture.

J Orthop Traumatol 2021 Mar 15;22(1):12. Epub 2021 Mar 15.

Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, 13620, Gyeonggi, Korea.

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.
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http://dx.doi.org/10.1186/s10195-021-00575-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960829PMC
March 2021

Changes in the bony alignment of the foot after tendo-Achilles lengthening in patients with planovalgus deformity.

J Orthop Surg Res 2021 Feb 8;16(1):118. Epub 2021 Feb 8.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, Republic of Korea.

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.
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http://dx.doi.org/10.1186/s13018-021-02272-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869243PMC
February 2021

Growth arrest and its risk factors after physeal fracture of the distal tibia in children and adolescents.

Injury 2021 Apr 14;52(4):844-848. Epub 2021 Jan 14.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea. Electronic address:

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.
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http://dx.doi.org/10.1016/j.injury.2021.01.014DOI Listing
April 2021

Remodelling of femoral head deformity after hip reconstructive surgery in patients with cerebral palsy.

Bone Joint J 2021 Jan;103-B(1):198-203

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea.

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: 2021;103-B(1):198-203.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-1339.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954150PMC
January 2021

Patients' perspectives on the conventional synthetic cast a newly developed open cast for ankle sprains.

World J Orthop 2020 Nov 18;11(11):492-498. Epub 2020 Nov 18.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam 463-707, Gyeonggi, South Korea.

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.
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http://dx.doi.org/10.5312/wjo.v11.i11.492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672803PMC
November 2020

Differences in responses to English and Korean versions of the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD).

Health Qual Life Outcomes 2020 Aug 17;18(1):282. Epub 2020 Aug 17.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Sungnam, Gyeonggi, 13620, South Korea.

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.
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http://dx.doi.org/10.1186/s12955-020-01528-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433359PMC
August 2020

Shielding effect of radiation dose reduction fiber during the use of C-arm fluoroscopy: a phantom study.

J Radiat Res 2020 Sep;61(5):705-711

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Korea.

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.
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http://dx.doi.org/10.1093/jrr/rraa060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482166PMC
September 2020

Factors Affecting Subjective Symptoms in Children with Pes Planovalgus Deformity: A Study Using the Oxford Ankle Foot Questionnaire.

J Bone Joint Surg Am 2020 Sep;102(17):1479-1485

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea.

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.
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http://dx.doi.org/10.2106/JBJS.19.01504DOI Listing
September 2020

Development and Validation of a Mobile Application for Measuring Femoral Anteversion in Patients With Cerebral Palsy.

J Pediatr Orthop 2020 Jul;40(6):e516-e521

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Sungnam, Gyeonggi Province.

Background: Computed tomography (CT) provides benefits for 3-dimensional (3D) visualization of femur deformities. However, the potential adverse effects of radiation exposure have become a concern. Consequently, a biplanar imaging system EOS has been proposed to enable reconstruction of the 3D model of the femur. However, this system requires a calibrated apparatus, the cost of which is high, and the area occupied by it is substantial. The purpose of this study was to develop a mobile application that included a new method of 3D reconstruction of the femur from conventional radiographic images and to evaluate the validity and reliability of mobile the application when measuring femoral anteversion.

Methods: The statistical shape model, graph-cut algorithm, and iterative Perspective-n-Point algorithm were utilized to develop the application. The anteroposterior and lateral images of a femur can be input using the embedded camera or by file transfer, and the touch interface aids accurate contouring of the femur. Regarding validation, the CT scans and conventional radiographic images of 36 patients with cerebral palsy were used. To evaluate concurrent validity, the femoral anteversion measurements on the images reconstructed from the mobile application were compared with those from the 3D CT images. Three clinicians assessed interobserver reliability.

Results: The mobile application, which reconstructs the 3D image from conventional radiographs, was successfully developed. Regarding concurrent validity, the correlation coefficient between femoral anteversion measured using 3D CT and the mobile application was 0.968 (P<0.001). In terms of interobserver reliability, the intraclass correlation coefficient among the 3 clinicians was 0.953.

Conclusions: The measurement of femoral anteversion with the mobile application showed excellent concurrent validity and reliability in patients with cerebral palsy. The proposed mobile application can be used with conventional radiographs and does not require additional apparatus. It can be used as a convenient technique in hospitals that cannot afford a CT machine or an EOS system.

Level Of Evidence: Level III-diagnostic.
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http://dx.doi.org/10.1097/BPO.0000000000001468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274151PMC
July 2020

Factors affecting GDI improvement after single event multilevel surgery in patients with cerebral palsy.

Gait Posture 2020 07 25;80:101-105. Epub 2020 May 25.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi 13620, Republic of Korea. Electronic address:

Background: Pathologic gait is common in patients with cerebral palsy (CP). Single-event multilevel surgery (SEMLS) is a combination of surgical procedures to improve pathologic gait in patients with CP. However, the effect of each procedure is difficult to predict. The gait deviation index (GDI) is useful in comparing pre- and postoperative improvement.

Research Question: In this study, we evaluated the degree of GDI improvement in patients with CP and analyzed factors related to surgical outcomes.

Methods: We screened patients seen between May 2003 and December 2019 via a clinical data warehouse to identify those with CP who had been followed up for >1 year and who had undergone SEMLS. The inclusion criteria were (1) CP patients with GMFCS levels I, II and III, (2) patients who underwent SEMLS, (3) and patients who underwent 3D gait analyses preoperatively and at least 1 year postoperatively. A linear mixed model was used to model GDI improvement, assess effects of covariates, and examine factors that contributed to improvement.

Results: Overall, 544 patients were included. The average improvement in overall GDI was 8.9 ± 12.3, 9.6 ± 12.0, and 6.4 ± 8.6 in Gross Motor Function Classification System (GMFCS) levels I, II, and III, respectively. In GMFCS level II patients, GDI improvement decreased by 0.26 points with a 1-year delay in surgery (p = 0.0022). Within each group of GMFCS levels, femoral derotation osteotomy (FDO) was a significant factor in GDI improvement in GMFCS levels I and II. Rectus femoris transfer (RFT) and supracondylar extension osteotomy (SCO) were significant factors in GMFCS level II. No single procedure was shown to affect improvement in GMFCS level III.

Significance: Postoperative GDI improved in all levels of GMFCS. Particular procedures especially affected postoperative improvement in GDI in levels I and II. Our data do not mean to set an indication for particular procedures; however, in GMFCS levels I, II patients, particular procedures, such as FDO, yielded a greater GDI improvement in our data set.
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http://dx.doi.org/10.1016/j.gaitpost.2020.05.033DOI Listing
July 2020

Genu varum deformity due to premature epiphyseal closure after treatment with isotretinoin for neuroblastoma: A case report.

J Orthop Surg (Hong Kong) 2020 Jan-Apr;28(2):2309499020924483

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea.

Isotretinoin, a vitamin A derivative, is known to induce premature epiphyseal closure. We report the case of a 9-year-old boy with neuroblastoma who demonstrated premature epiphyseal closure after 1 year of isotretinoin treatment (72.3 mg/m/day). A bone bridge developed on the bilateral proximal tibial growth plate resulting in genu varum. We performed hemiepiphysiodesis on the bilateral proximal tibia in anticipation of the spontaneous resolution of the bone bridge. Genu varum on the left side was corrected with the resolution of bone bridge. For the remaining bone bridge on the right side, arthroscopy-assisted physeal bar resection was performed, and genu varum on the right lower extremity was also corrected. A regular review of the alignment of the upper and lower limbs is necessary to provide timely intervention in patients using isotretinoin, considering the possibility of premature epiphyseal closure.
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http://dx.doi.org/10.1177/2309499020924483DOI Listing
February 2021

Transcultural adaptation and validation of a Korean version of the Oxford Ankle Foot Questionnaire for children.

Health Qual Life Outcomes 2020 May 1;18(1):118. Epub 2020 May 1.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Seongnam, 13620, Gyeonggi, Republic of Korea.

Background: The purpose of this study was to translate and transculturally adapt the original English version of the Oxford Ankle Foot Questionnaire (OAFQ) into a Korean version, and to evaluate its psychometric properties.

Methods: A Korean OAFQ for children was developed according to established guidelines. To test validity, 169 consecutive patients with foot and ankle problems and their caregivers each completed the OAFQ. The children also completed a Korean version of the KIDSCREEN-52 health related quality of life questionnaire (KIDSCREEN-52 HRQOL). To validate the Korean version of the OAFQ, reliability (child-parent agreement and internal consistency), feasibility (floor and ceiling effects), and construct validity were evaluated, and factor analysis was performed.

Results: In terms of reliability, Cronbach's α values were > 0.7 in all subscales of the OAFQ (0.765 to 0.901). Child-parent agreement was confirmed by high intraclass correlation coefficients for all subscales (0.791 to 0.863). In terms of construct validity, there were moderate correlations between the subscales of the OAFQ and the subscales of the KIDSCREEN-52 HRQOL. Factor analysis revealed a three-component solution for both the child/adolescent and parent-proxy version, by combining the school and play, and footwear items into one subscale. In terms of feasibility, no floor effects were found for all subscales. However, ceiling effects were observed for the school and play, and emotional subscales for child/adolescent and parent-proxy versions.

Conclusions: The OAFQ was successfully translated and transculturally adapted into the Korean language; the Korean version of the OAFQ represents a reliable and valid instrument for evaluating children's foot or ankle problems. However, factor analysis suggested the use of a three-subscale questionnaire.
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http://dx.doi.org/10.1186/s12955-020-01378-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195794PMC
May 2020

Discrepancy between true ankle dorsiflexion and gait kinematics and its association with severity of planovalgus foot deformity.

BMC Musculoskelet Disord 2020 Apr 16;21(1):250. Epub 2020 Apr 16.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea.

Background: In planovalgus deformity with triceps contracture, a midfoot break happens, and ankle dorsiflexion (ADF) occurs at the mid-tarsal joint during gait. Results of standard 3D gait analysis may misinterpret the true ankle dorsiflexion because it recognizes the entire foot as a single rigid segment. We performed this study to investigate whether the severity of planovalgus deformity is associated with the discrepancy between the value of ADF evaluated by physical examination and 3-dimensional (3D) gait analysis. In addition, we aimed to identify the radiographic parameters associated with this discrepancy and their relationships.

Methods: Consecutive 40 patients with 65 limbs (mean age, 11.7 ± 5.5 years) with planovalgus foot deformity and triceps surae contracture were included. All patients underwent 3D gait analysis, and weightbearing anteroposterior (AP) and lateral (LAT) foot radiographs. ADF with knee extension was measured using a goniometer with the patient's foot in an inverted position.

Results: Twenty-one limbs underwent operation for planovalgus foot deformity, and 56 limbs underwent operation for equinus deformity. The difference between ADF on physical examination and ADF at initial contact on gait analysis was 17.5 ± 8.4°. Differences between ADF on physical examination and ADF at initial contact on gait analysis were significantly associated with the LAT talus-first metatarsal angle (p = 0.008) and calcaneal pitch angle (p = 0.006), but not associated with the AP talus-first metatarsal angle (p = 0.113), talonavicular coverage angle (p = 0.190), talocalcaneal angle (p = 0.946), and naviculocuboid overlap (p = 0.136).

Conclusion: The discrepancy between ADF on physical examination and 3D gait analysis was associated with the severity of planovalgus deformity, which was evaluated on weightbearing LAT foot radiographs. Therefore, physicians should be cautious about interpreting results from 3D gait analysis and perform a careful physical examination to assess the degree of equinus deformity in patients with planovalgus foot deformity.
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http://dx.doi.org/10.1186/s12891-020-03285-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164230PMC
April 2020

Post-traumatic avascular necrosis of tibial plafond following an ankle fracture.

J Orthop Sci 2020 Mar 5. Epub 2020 Mar 5.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea. Electronic address:

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http://dx.doi.org/10.1016/j.jos.2020.01.016DOI Listing
March 2020

Progression of planovalgus deformity in patients with cerebral palsy.

BMC Musculoskelet Disord 2020 Mar 3;21(1):141. Epub 2020 Mar 3.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea.

Background: Analyzing radiographic changes of pes planovalgus(PV) deformity of cerebral palsy(CP) patients according to age and influencing factors.

Methods: CP patients with PV deformity younger than 18 years old who had undergone more than a year of follow-up with at least two standing foot radiographs were included. Anteroposterior and lateral talo-first metatarsal(talo-1stMT), talo-second metatarsal(talo-2ndMT), and hallux valgus(HV) angles were measured on the radiographs. The rate of progression was adjusted by multiple factors using the linear mixed model, with the Gross Motor Function Classification System(GMFCS) level as the fixed effect and age and each subject as random effects.

Results: Overall, 194 patients were enrolled in this study, and 1272 standing foot radiographs were evaluated. The AP talo-2MT angle progressed by 0.59° (p < 0.0001) and 0.64° (p = 0.0007) in GMFCS level II and III patients, respectively; however, there was no significant change in GMFCS level I patients (p = 0.3269). HV was significantly affected by age in all three GMFCS groups; it increased by 0.48° (p < 0.0001), 0.66° (p < 0.0001), and 1.19° (p < 0.0001) for levels I, II, and III, respectively. The lateral talo-1stMT angle showed improvements in GMFCS level I and II patients (0.43°, p < 0.0001, and 0.61°, p < 0.0001, respectively). In GMFCS level III patients, there was no significant improvement in the lateral talo-1MT angle (p = 0.0535).

Conclusions: The GMFCS level was the single most important factor influencing the progression of radiographic indices in PV deformity in CP. The AP talo-1MT and talo-2ndMT angles progressed in patients with GMFCS levels II and III. Physicians should take this result into consideration when planning the timing of the surgery.

Level Of Evidence: Prognostic Level IV.
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http://dx.doi.org/10.1186/s12891-020-3149-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7055068PMC
March 2020

Correlation between Accelerometer and Questionnaire-Based Assessment of Physical Activity in Patients with Cerebral Palsy.

Clin Orthop Surg 2020 Mar 13;12(1):107-112. Epub 2020 Feb 13.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.

Background: Precise measuring and monitoring of physical activity (PA) in patients with cerebral palsy (CP) are critical for assessing their PA participation and its potential health benefits. Accelerometer-based assessment of PA has been considered valid, reliable, and practical in children with CP. Therefore, we investigated the correlation between accelerometer- and questionnaire-based assessment of PA in CP patients.

Methods: Nineteen patients with CP who were classified as Gross Motor Function Classification System level I-III and 84 normally developed participants were included in the study. Study participants wore an accelerometer for seven days, after which they visited the hospital and completed the International Physical Activity Questionnaire (IPAQ). CP patients and their caregivers completed the Pediatric Outcomes Data Collection Instrument (PODCI) and the Caregiver Priorities and Child Health Index of Life with Disabilities, respectively. The concurrent validity of the questionnaires was assessed.

Results: In the accelerometer-based assessment, time spent in PA was significantly shorter at every intensity level in CP patients than in normally developed participants. However, PA assessed by the IPAQ was significantly higher in patients with CP, indicating that they tend to exaggerate their participation in PA. On the correlation of the assessment by the accelerometer and by the PODCI, transfer/basic mobility, sports/physical function, and happiness increased significantly as the number of steps taken and the distance travelled increased.

Conclusions: In patients with CP, happiness and quality of life are associated with higher levels of PA. Thus, programs for patients with CP should focus on improving their PA.
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http://dx.doi.org/10.4055/cios.2020.12.1.107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031426PMC
March 2020

Surgical outcomes after single event multilevel surgery in cerebral palsy patients with mid-stance knee hyperextension.

Gait Posture 2020 03 10;77:1-5. Epub 2020 Jan 10.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea. Electronic address:

Background: Some patients with cerebral palsy (CP) exhibit excessive knee flexion at initial contact followed by knee hyperextension (KE) in mid-stance.

Research Question: This study investigated the change in sagittal kinematics after distal hamstring lengthening (DHL) and triceps surae lengthening procedures in CP patients with KE, and compared it to those without KE. In addition, the risk factors for the worsening of postoperative KE were analyzed.

Methods: Consecutive 312 patients (596 limbs) with CP who underwent DHL and triceps surae lengthening were included. All patients underwent preoperative and 1-year postoperative three-dimensional gait analysis. Patients' limbs were divided into the KE and knee flexion (KF) groups, according to preoperative minimum knee flexion in stance. KE was defined as minimum knee flexion in stance less than 0°.

Results: The KE and KF groups included 130 and 466 limbs, respectively. Knee and ankle sagittal kinematics significantly improved after surgery in both groups. Minimum knee flexion in stance significantly increased from -6.6˚ to 0.5˚ in the KE group, but decreased from 14.6˚ to 7.8˚ in the KF group. Among the KE group, minimum knee flexion in stance improved in 103 limbs (79.2 %), but worsened in 27 limbs (20.8 %). Degree of preoperative KE was the only factor significantly associated with postoperative worsening of KE (p=0.002). The cutoff value for the worsening of KE was -5.8˚ of preoperative minimum knee flexion in stance.

Significance: This study demonstrated that the sagittal kinematics of the knee and ankle joints improved after DHL and triceps surae lengthening procedures in CP patients with and without KE. Preoperative degree of KE was a risk factor for the worsening of KE after surgery. Therefore, careful selection for indication of DHL is required to prevent postoperative KE due to overlengthening of the hamstrings, particularly in patients with severe preoperative KE.
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http://dx.doi.org/10.1016/j.gaitpost.2020.01.005DOI Listing
March 2020

Cluster of Lymphadenitis due to Nontuberculous Mycobacterium in Children and Adolescents 8-15 Years of Age.

J Korean Med Sci 2019 Dec 2;34(46):e302. Epub 2019 Dec 2.

Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

Background: Nontuberculous mycobacteria (NTM) lymphadenitis is an under-recognized entity, and data of the true burden in children are limited. Without a high index of suspicion, diagnosis may be delayed and microbiological detection is challenging. Here, we report a cluster of NTM lymphadenitis experienced in Korean children.

Methods: Subjects under 19 years of age diagnosed with NTM lymphadenitis during November 2016-April 2017 and April 2018 were included. Electronic medical records were reviewed for clinical, laboratory and pathological findings. Information regarding underlying health conditions and environmental exposure factors was obtained through interview and questionnaires.

Results: A total of ten subjects were diagnosed during 18 months. All subjects were 8-15 years of age, previously healthy, male and had unilateral, nontender, cervicofacial lymphadenitis for more than 3 weeks with no significant systemic symptoms and no response to empirical antibiotics. Lymph nodes involved were submandibular (n = 8), preauricular (n = 6) and submental (n = 1). Five patients had two infected nodes and violaceous discoloration was seen in seven subjects. Biopsy specimens revealed chronic granulomatous inflammation and acid-fast bacteria culture identified in two cases and NTM polymerase chain reaction was positive in two cases. Survey revealed various common exposure sources.

Conclusion: NTM lymphadenitis is rare but increasing in detection and it may occur in children and adolescents. Diagnosis requires high index of suspicion and communication between clinicians and the laboratory is essential for identification of NTM.
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http://dx.doi.org/10.3346/jkms.2019.34.e302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882942PMC
December 2019

Effects of soft tissue surgery on transverse kinematics in patients with cerebral palsy.

BMC Musculoskelet Disord 2019 Nov 27;20(1):566. Epub 2019 Nov 27.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, Republic of Korea.

Background: Gait disturbances, including flexed knee gait, stiff knee gait, and tip-toeing gait, are common in patients with cerebral palsy (CP). There has been no reports regarding kinematic changes in the transverse plane after soft tissue surgeries, such as distal hamstring lengthening (DHL), rectus femoris transfer (RFT), and tendo-Achilles lengthening (TAL). This study aimed to evaluate changes in the transverse plane after soft tissue surgery in patients with CP by assessing the effects of the DHL, RFT, and TAL.

Methods: The study enrolled 156 consecutive patients (mean age, 8.4 years; range, 4.4 to 20.9), representing 213 operated limbs, who underwent soft tissue surgery including DHL with semitendinosus transfer, RFT, and TAL. All patients were assessed by preoperative and 1-year postoperative three-dimensional gait analysis. Changes in transverse plane kinematics after soft tissue surgery and affecting factors were analyzed.

Results: Sagittal kinematics including knee flexion at initial contact, ankle dorsiflexion at initial contact, and mean ankle dorsiflexion in the stance phase were significantly improved after single event multilevel surgery (all p < 0.001). Transverse kinematics, including mean tibial rotation and foot progression angle, were significantly improved to a more external angle after soft tissue surgeries (- 2.9°, p = 0.004 and - 9.5°, p < 0.001). The mean hip rotation was significantly improved to a more external angle by RFT (- 4.7°, p = 0.010) and the foot progression angle was significantly improved to a more external angle by TAL (- 3.9°, p = 0.028).

Conclusions: This study found that the transverse kinematics were improved to a more external angle after soft tissue surgery in patients with CP. Therefore, clinicians should consider that soft tissue surgery can affect the transverse plane kinematics in patients with CP. To confirm our findings, further research regarding the natural history of femoral and tibial torsion in children with CP is needed.
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http://dx.doi.org/10.1186/s12891-019-2955-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882030PMC
November 2019

Analysis of three-dimensional computed tomography talar morphology in relation to pediatric pes planovalgus deformity.

J Pediatr Orthop B 2019 Nov;28(6):591-597

Department of Orthopedic Surgery, Soon Chun Hyang University Hospital, Cheonan, South Korea.

Intraosseous alignment of the tarsal bone has not been investigated in relation to various foot deformities. This study aimed to investigate three-dimensional computed tomography (3D CT) talar morphology in children with idiopathic and neuromuscular pes planovalgus. Eleven children [nine boys, two girls; mean (SD) age: 10.5 (2.8) years] with idiopathic pes planovalgus and 15 children [three boys, 12 girls; mean (SD) age: 10.8 (3.4) years] with neuromuscular pes planovalgus were included. All patients underwent 3D CT and weight-bearing anteroposterior, lateral, and axial radiography. Demographic data and talar 3D CT and radiographic measurements were compared between both groups. The correlation between the measurements was also analyzed. The neuromuscular group showed significantly more severe deformity than the idiopathic group in the radiographic and 3D sagittal talus measurements. The 3D coronal talus measurement showed a significant negative correlation with the axial hindfoot alignment in the idiopathic group while the 3D transverse talus measurement was significantly correlated with the lateral talocalcaneal angle in the neuromuscular group. 3D intraosseous alignment of the talus is correlated with pes planus deformity. Longitudinal and biomechanical studies including a control group are necessary to elucidate the role of 3D talar morphology on a dynamic imbalance in pes planovalgus.
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http://dx.doi.org/10.1097/BPB.0000000000000597DOI Listing
November 2019

Inverse Relationship Between Radiographic Lateral Ankle Instability and Osteochondral Lesions of the Talus in Patients With Ankle Inversion Injuries.

Foot Ankle Int 2019 Dec 27;40(12):1368-1374. Epub 2019 Aug 27.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.

Background: Insufficient or excessive bony constraint surrounding the talus might contribute to the occurrence of ligamentous injury or bone contusion, respectively, at the time of ankle inversion injuries. This study aimed to investigate the relationship between radiographic lateral ankle instability and osteochondral lesions of the talus (OLT) following ankle inversion injuries.

Methods: A total of 195 patients (113 men and 83 women; mean age, 38.7 years) with a history of ankle inversion injuries were included in this study. All patients underwent ankle magnetic resonance imaging (MRI) and stress radiography. The tibiotalar tilt angle on varus stress radiograph, anterior translation of the talus on anterior-drawer lateral radiographs, bimalleolar tilt angle, and fibular position were radiographically determined. The radiographic lateral ankle instability was defined as tibiotalar tilt angle ≥10 degrees, and the presence of OLT was confirmed on MR images. The relationship between the radiographic lateral ankle instability and the presence of OLT was statistically analyzed.

Results: The presence of radiographic lateral ankle instability (tibiotalar tilt angle ≥10 degrees) showed an inverse relationship with that of OLT in the chi-squared test ( = .003). An increased tibiotalar tilt angle was associated with lower incidence of OLT ( = .011) in the multiple regression analysis, and the presence of OLT was associated with a decreased tibiotalar tilt angle ( = .016) in the binary logistic regression analysis.

Conclusions: This study showed an inverse relationship between lateral ankle instability and the development of OLT following ankle inversion injury. The role of bony constraint in the development of sports injuries in the ankle should be considered with these injuries.

Level Of Evidence: Level III, diagnostic, comparative study.
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http://dx.doi.org/10.1177/1071100719868476DOI Listing
December 2019

A suspicious atypical fracture of 5th metatarsal bone: A case report.

J Orthop Sci 2019 Feb 14. Epub 2019 Feb 14.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, South Korea. Electronic address:

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http://dx.doi.org/10.1016/j.jos.2019.01.007DOI Listing
February 2019

Radiographic changes of the mid-tarsal joint after calcaneal lengthening for planovalgus foot deformity.

Foot Ankle Surg 2020 Jan 31;26(1):110-115. Epub 2018 Dec 31.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Seongnam, Gyeonggi 13620, South Korea. Electronic address:

Background: This study evaluate the radiographic changes in the mid-tarsal joint, including the calcaneocuboid and talonavicular (TN) joints after calcaneal lengthening for planovalgus deformity in children.

Methods: This study included 38 patients (68 feet) who underwent calcaneal lengthening for planovalgus deformity. Radiographic osteoarthritic changes at the CC or TN joint were defined as modified Kellgren-Lawrence grade of ≥1.

Results: Among the 68 feet, 31 feet (45.6%) showed radiographic osteoarthritic changes at the CC joint and 20 (29.4%) showed changes at the TN joint. Risk of radiographic osteoarthritic changes at the CC joint was associated with increased age at surgery (OR = 1.2, p = 0.038). Risk of radiographic osteoarthritic changes at the TN joint was associated with increased age at surgery (OR = 2.2; p = 0.002), preoperative AP talus-1st metatarsal angle (OR = 1.1; p = 0.044), and degree of CC subluxation (OR = 2.1; p = 0.007).

Conclusions: Surgeons should consider the risk factors in the surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.
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http://dx.doi.org/10.1016/j.fas.2018.12.008DOI Listing
January 2020

Use of iliac crest allograft for Dega pelvic osteotomy in patients with cerebral palsy.

BMC Musculoskelet Disord 2018 Oct 16;19(1):375. Epub 2018 Oct 16.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea.

Background: Dega pelvic osteotomy is commonly performed procedure in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for hip displacement. However, there has been no study investigating the outcomes after Dega pelvic osteotomy using allograft in patients with CP. This study investigated the outcomes of Dega pelvic osteotomy using iliac crest allograft in CP with hip displacement and the factors affecting allograft incorporation.

Methods: This study included 110 patients (150 hips; mean age 8y7mo; 68 males, 42 females) who underwent hip reconstructive surgeries including Dega pelvic osteotomy using iliac crest allograft. To evaluate the time of allograft incorporation, Goldberg score was evaluated according to the follow-up period on all postoperative hip radiographs. The acetabular index, migration percentage, and neck-shaft angle were also measured on the preoperative and postoperative follow-up radiographs.

Results: The mean estimated time for allograft incorporation (Goldberg score ≥ 6) was 1.1 years postoperatively. All hips showed radiographic union at the final follow-up and there was no case of graft-related complications. Patients with Gross Motor Function Classification System (GMFCS) level V had 6.9 times higher risk of radiographic delayed union than those with GMFCS level III and IV. Acetabular index did not increase during the follow-up period (p = 0.316).

Conclusions: Dega pelvic osteotomy using iliac crest allograft was effective in correcting acetabular dysplasia, without graft-related complications in patients with CP. Furthermore, the correction of acetabular dysplasia remained stable during the follow-up period.
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http://dx.doi.org/10.1186/s12891-018-2293-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6192369PMC
October 2018

Natural progression of radiographic indices in juvenile hallux valgus deformity.

Foot Ankle Surg 2019 Jun 10;25(3):378-382. Epub 2018 Feb 10.

Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea. Electronic address:

Background: This study aimed to estimate the annual change in radiographic indices for juvenile hallux valgus (JHV) and to analyze the factors that influence deformity progression.

Methods: Patients aged <15 years who had JHV and were followed up for at least 1 year were included. Hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-first metatarsal angle, and lateral talo-first metatarsal angle were evaluated. The progression rate of HVA was adjusted by multiple factors by using a linear mixed model.

Results: A total of 133 feet were included. The HVA and distal metatarsal articular angle both increased by 0.8° per year (p<0.001 and p=0.003, respectively). HVA increased by 1.5° per year (p<0.001) at under the age of 10, and the HVA progression in the older patients was not statistically significant.

Conclusions: JHV deformity could progress with aging. Most deformity progression could occur before the age of 10 years.
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http://dx.doi.org/10.1016/j.fas.2018.02.001DOI Listing
June 2019
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