Publications by authors named "Moon Seok Park"

211 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

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

Radiographic differences in the concomitant deformities in two types of medial ankle osteoarthritis.

PLoS One 2021 3;16(3):e0247816. Epub 2021 Mar 3.

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

Objectives: Motion preserving surgeries could be unsuccessful because of underestimation of deformities of the foot and knee in ankle osteoarthritis. This study aimed to investigate the concomitant deformities in medial ankle osteoarthritis and the difference between the two types, varus angulation and medial translation.

Methods: A retrospective study was conducted using medical records and radiographic data. Patients with medial ankle osteoarthritis that underwent weight-bearing X ray imaging and radiographic measurements including tibial plafond inclination (TPI), tibiotalar tilt angle (TT), lateral talo-first metatarsal angle, naviculo-cuboid overlap, and mechanical tibiofemoral angle (mTFA) were studied. The patients were categorized into two groups, the varus angulation group (TT ≥4°) and medial translation group (TT <4°). The radiographic measurements were compared between the two groups.

Results: A total of 102 patients (male = 44; female = 58) were included; the mean age was 64.9 years (SD 8.3 years). The varus rotation group (N = 66) showed a significantly smaller lateral talo-first metatarsal angle (p<0.001), naviculo-cuboid overlap (p<0.001), and mTFA (p = 0.019) compared to the medial displacement group (N = 36). The TT showed a significant correlation with lateral talo-first metatarsal angle (r = -0.520, p<0.001), naviculo-cuboid overlap (r = -0.501, p<0.001), and mTFA (r = -0.243, p = 0.014). Lateral talo-first metatarsal angle was found to be the significant factor (p = 0.018) discriminating varus angulation and medial translation types in the binary logistic analysis.

Conclusions: Varus angulation of the ankle was correlated with knee alignment and foot deformity. Radiographic indices were different between the varus angulation and medial translation groups. The role of concomitant deformities needs to be further investigated in terms of a causal relationship. Surgeons need to pay attention to concomitant deformities in the treatment of medial ankle osteoarthritis.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247816PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928528PMC
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

Effects of creative dance-based exercise on gait performance in adolescents with cerebral palsy.

J Exerc Rehabil 2020 Aug 25;16(4):332-343. Epub 2020 Aug 25.

Department of Physical Education, Seoul National University, Seoul, Korea.

The purpose of this study is to explore the feasibility and therapeutic potential of creative dance (CD) based exercise as a rehabilitation intervention for adolescents with cerebral palsy (CP). Participants were 10 adolescents with spastic CP (mean age, 17.5±2.12 years; Gross Motor Function Classification System levels I [n=3] and II [n=7]). Outcome measures included the Gross Motor Function Measure-88 (GMFM-88; dimensions D and E), spatiotemporal gait parameters, lower limb range of motion during walking, and body image, assessed using the Body Cathexis Scale (BCS). CD was provided in 2-hr classes, twice weekly, for 12 weeks, during which participants learned movement concepts and developed their own movement. All participants completed the intervention, with an attendance rate of 98% and high satisfaction rating. GMFM-88 dimensions D (=0.01) and E (=0.005); walking speed (= 0.005), cadence (=0.009), step (=0.005), and stride length (=0.005); and sagittal ranges of motions of hip (=0.009) and ankle (=0.03) during walking were significantly improved. The time of opposite foot off (=0.028) and first double-limb support (=0.028) significantly decreased, whereas the percentage of single-limb support time (=0.02) increased. Additionally, BCS scores were significantly improved. In conclusions, CD-based exercise can improve gross motor function, gait performance, and body image in adolescents with CP.
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http://dx.doi.org/10.12965/jer.2040384.192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463062PMC
August 2020

Posterior Tibial Tendon Integrity Can Be Screened With Plain Anteroposterior Foot Radiography.

Orthopedics 2020 Nov 3;43(6):e503-e507. Epub 2020 Sep 3.

Posterior tibial tendon integrity is an important consideration when treating adult-acquired flatfoot caused by posterior tibial tendon dysfunction. The condition of this tendon traditionally has been evaluated with ultrasonography or magnetic resonance imaging, but recent advances in radiography have increased the resolution of radiographic soft tissue images. The authors examined whether the posterior tibial tendon could be screened with anteroposterior foot radiographs, based on interobserver agreement and accuracy. The authors retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by 2 orthopedic surgeons with foot radiographs and scored as normal or abnormal. The authors evaluated interobserver agreement and compared the findings of ultrasonography and radiography to evaluate diagnostic accuracy. The study included 21 patients with a mean age of 51.5±15.7 years. Ultrasonography showed that 4 patients had normal tendon integrity, 6 patients had tenosynovitis and no tendinopathy, 8 patients had tendinopathy and tendon continuity, and 3 patients had loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of patients (17 of 21). On the basis of the ultrasonographic findings, the surgeons' accuracy was 76.2% (16 of 21) and 61.9% (13 of 21). The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow orthopedic surgeons to predict the prognosis of patients with posterior tibial tendon dysfunction, determine the extent of surgical treatment, and evaluate tendon integrity postoperatively. [Orthopedics. 2020;43(6):e503-e507.].
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http://dx.doi.org/10.3928/01477447-20200827-04DOI Listing
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

Aggravation of Ankle Varus Incongruency Following Total Knee Replacement Correcting ≥10° of Genu Varum Deformity: A Radiographic Assessment.

J Arthroplasty 2020 11 17;35(11):3305-3310. Epub 2020 Jun 17.

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

Background: This study aimed to investigate the change in ankle varus incongruencies following total knee replacement (TKR) in patients with preoperative genu varum deformity of ≥10°.

Methods: The study cohort was composed of patients who underwent TKR in a single institution for knee osteoarthritis with preoperative genu varum deformity of ≥10° and concomitant varus ankle incongruencies. Eight radiographic measurements were evaluated preoperatively and postoperatively: mechanical tibiofemoral angle, mechanical lateral distal femoral angle, medial proximal tibial angle, lateral distal tibial angle, tibial plafond inclination, talar inclination, tibiotalar tilt angle (TTTA), and tibia-mechanical axis angle. Of these, TTTA represented the quantitative degree of ankle joint incongruency.

Results: A total of 110 patients (male = 2; female = 108) were included in the analysis. The mean patient age was 68.9 (standard deviation [SD] 7.2) years at the time of TKR. All radiographic measurements showed significant changes postoperatively, representing the appropriate correction of genu varum deformity and restoration of the mechanical axis. Nineteen patients (17.3%) showed postoperative decrease in TTTA, 2 (1.8%) remained the same, and 89 (80.9%) showed increase. Overall, mean preoperative and postoperative TTTA were 3.3° (SD 2.2°) and 4.7° (SD 2.9°), respectively (P < .001), representing the aggravation of varus ankle incongruencies.

Conclusion: Varus ankle incongruencies showed aggravation following TKR despite correction of genu varum deformity and restoration of the mechanical axis. This could be an important cause of postoperative increase or development of ankle pain following TKR. Therefore, patients with preoperative varus ankle incongruencies need to be warned of possible aggravation of ankle symptoms and be evaluated before TKR.

Level Of Evidence: Prognostic level III.
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http://dx.doi.org/10.1016/j.arth.2020.06.027DOI Listing
November 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

Diagnosis and Management of Hip Dislocation in Patients with Kabuki Syndrome.

Clin Orthop Surg 2019 Dec 12;11(4):474-481. Epub 2019 Nov 12.

Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Korea.

Background: Kabuki syndrome is a rare genetic disorder characterized by distinct dysmorphic facial features, growth deficiency, intellectual disabilities, unusual dermatoglyphic patterns, and skeletal abnormalities. The incidence of hip dislocation in Kabuki syndrome ranges from 18% to 62%. We reviewed the outcomes of management of hip dislocations in patients with Kabuki syndrome with special attention to the diagnostic processes for hip dislocation and Kabuki syndrome.

Methods: Among 30 patients with mutation-confirmed Kabuki syndrome, we selected six patients who had hip dislocations and reviewed their medical records and plain radiographs. The modes of presentation and diagnostic processes for both hip dislocations and Kabuki syndrome were investigated. The management and treatment outcomes of hip dislocations in patients with Kabuki syndrome were evaluated.

Results: The average age of patients at the time of diagnosis of hip dislocation was 7.7 months (range, 1 week to 22 months). None of the patients were diagnosed as having Kabuki syndrome at that time. Two patients were treated with a Pavlik harness; one, with closed reduction; two, with open reduction and later pelvic and/or femoral osteotomies; and one, with open reduction combined with pelvic osteotomy. The patients were followed up for 5.8 years on average (range, 2.0 to 10.5 years). The radiologic outcome was graded as Severin IA or IB for three patients who were older than 6 years at the latest follow-up (mean age, 9.9 years; range, 7.8 to 12.4 years). In the remaining three patients younger than 6 years (mean age, 3.8 years; range, 2.7 to 5.3 years), the lateral center edge angle was more than 15°. The clinical diagnosis of Kabuki syndrome was made during follow-up after hip dislocation treatment and confirmed by mutational analysis at a mean age of 4.7 years. The mean interval between the diagnosis of hip dislocation and Kabuki syndrome was 4.0 years.

Conclusions: The management of hip dislocation by conservative or surgical method showed successful results. Awareness of Kabuki syndrome could lead to an early diagnosis of this rare disease in patients with hip dislocation and allow for early detection of other underlying conditions and multidisciplinary management.
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http://dx.doi.org/10.4055/cios.2019.11.4.474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867925PMC
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

Overgrowth of the lower limb after treatment of developmental dysplasia of the hip: incidence and risk factors in 101 children with a mean follow-up of 15 years.

Acta Orthop 2020 04 12;91(2):197-202. Epub 2019 Nov 12.

Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul.

Background and purpose - There are few studies on overgrowth of the affected limb after treatment of developmental dysplasia of the hip (DDH). We investigated the incidence of overgrowth and its risk factors in DDH patients.Patients and methods - 101 patients were included in this study. Overgrowth was defined by 2 criteria: when the height of the femoral head of the affected side was higher than that of the contralateral side by more than 10 mm, or by more than 15 mm. The potential risk factors of distinct overgrowth were retrospectively examined using multivariable analysis.Results - When overgrowth was defined as femoral head height difference (FHHD) > 10 mm, its incidence was 44%, and only femoral osteotomy was identified as a significant risk factor with a relative risk (RR) of 1.6 (95% confidence interval [CI] 1.0-2.5). When overgrowth was defined as FHHD > 15 mm, its incidence was 23%, and femoral osteotomy was identified as the only significant risk factor with an RR of 2.3 (CI 1.2-4.5). Overgrowth developed more frequently in patients who underwent femoral osteotomy at the age of 2 to 4 years (87%) than in the others (46%) (p = 0.04).Interpretation - Overgrowth of the affected limb is common in DDH patients. Patients who underwent femoral osteotomy, especially at the age of 2 to 4 years, may require careful follow-up because of the substantial risk for overgrowth.
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http://dx.doi.org/10.1080/17453674.2019.1688485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144334PMC
April 2020

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
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