Changes in Dynamic Pedobarography after Extensive Plantarmedial Release for Paralytic Pes Cavovarus

PURPOSE: Plantarmedial release and first ray extension osteotomy are often combined to treat paralytic cavovarus foot deformity. The purpose of this study is to evaluate the effect of additional first ray extension osteotomy in terms of dynamic pedobarography. MATERIALS AND METHODS: We reviewed findings of pre- and postoperative plain radiography and dynamic pedobarography for 25 patients in whom the flexibility of the hindfoot was confirmed by the Coleman block test. The results of treatment by extensive plantar medial release with first ray osteotomy (group I) were compared with the results of treatment by extensive plantar medial release alone (group II). RESULTS: Plain radiographs obtained pre- and postoperatively showed no statistically significant improvement in each group. Only in group I, peak forces at the 1st metatarsal head, 2nd metatarsal head and medial calcaneus were increased after operation. CONCLUSION: In paralytic hindfoot flexible cavovarus, extensive plantarmedial release with first ray osteotomy improve foot pressure distribution more than extensive plantarmedial release alone.

Erratum to "Effects of Multiple Drilling on the Ischemic Capital Femoral Epiphysis of Immature Piglets" by Gong SY, et al. (Yonsei Med J 2011;52:809-17.)

No abstract available.

Changes of the Muscle-tendon Lengths in a Three-dimensional Musculoskeletal Model according to the Hip Transverse Angle in Cerebral Palsy Patients with Crouch Gait / 대한정형외과학회잡지

PURPOSE: Crouch gait is one of the common pathologic gaits in children with cerebral palsy. Hamstring lengthening for alleviation of knee flexion is often considered as a first choice for the treatment of crouch gait. However, there have been a variety of reports about the lengths of the hamstring muscle. The purpose of this study was to classify the crouch gait on the transverse plane and to suggest a guide line for hamstring lengthening by analyzing the length of these muscles. MATERIALS AND METHODS: The subjects for this study were selected in ambulatory spastic diplegia patients with crouch gait. A total of sixty-two patients (124 cases) were included. The gait parameters and the muscle lengths were compared. The range of +/-1 standard deviation of the normal middle stance hip rotation was considered as the normal range. The subjects were divided into three groups as hip external rotated (group I), normal (group II) and hip internal rotated (group III) according to the hip rotation. RESULTS: The flexion of the knee and hip was the greatest in group III and dorsiflexion of the ankle was the least in group I. On comparison of moment and power on the sagittal plane, there was no significant difference among the groups. In group III, the percent lengths of the adductor, biceps femoris and gracilis muscles were increased the most, whereas the percent length of the semimembranosus was decreased the most. There was no statistical difference between groups I and II and the normal control group. CONCLUSION: Irrespective of the hip rotation, the length of the hamstring muscle in patients with crouch gait did not differ compared to that of the normal control. But if rotational osteotomy is done for the correction of the increased femoral anteversion in group III, then we should consider lengthening the semimembranosus muscle.

Effects of Multiple Drilling on the Ischemic Capital Femoral Epiphysis of Immature Piglets

PURPOSE: This study investigated the effects of multiple drilling on the immature capital femoral epiphysis following ischemic injury in a piglet model. MATERIALS AND METHODS: Ischemic necrosis of capital femoral epiphysis was induced bilaterally in 12 piglets using a cervical ligation method. Three weeks later, medial, central, and lateral 3 drill holes were made on the left femoral head using 0.062" K-wire. At 3, 6, 9, and 12 weeks following the multiple drilling, femoral heads were harvested from each three piglets. On histologic examination, percent of revascularization, percent of osteoblast surface, capital femoral epiphyseal quotient and proximal femoral growth plate height were evaluated. Untreated right femoral heads served as control. RESULTS: While percent of revascularization of left capital femoral epiphysis with multiple drilling was significantly higher than untreated control side (p<0.001), percent of osteoblast surface, capital femoral epiphyseal quotient and proximal femoral growth plate height showed no significant difference. CONCLUSION: This study indicates that multiple drilling could promote revascularization of ischemic capital femoral epiphysis, and multiple drilling does not appear to produce bony physeal bars at short-term, if using small diameter drill. However, multiple drilling alone does not seem to prevent femoral head deformity or to promote new bone formation.

Limb Angular Deformity Correction Using Dyna-ATC: Surgical Technique, Calculation Method, and Clinical Outcome

PURPOSE: Dyna-ATC is a unilateral external fixator with angulator, lengthener, and translator, which allows for angular correction and compensation of the secondary displacement during angular correction. The purpose of this study is to introduce surgical technique and calculation methods and to evaluate the clinical outcome of angular deformity correction using Dyna-ATC. MATERIALS AND METHODS: The amounts of secondary displacement were calculated with the distances between axis of correction of angulation, Center of Rotational Angulation, and osteotomy and the amount of angular deformity. The rate of angular correction was determined to distract the corticotomy at 1 mm/day. Clinical and radiographic evaluation was performed on 13 patients who underwent deformity correction using Dyna-ATC. There were 8 proximal tibia vara, 1 tibia valga, 2 varus and 4 valgus deformities on distal femur. One patient underwent pelvic support femoral reconstruction. Concomitant lengthening was combined in all femur cases. Mean age at surgery was 17.5 years (7 to 64). RESULTS: All but one achieved bony healing and normal alignment with the index procedure. Mean mechanical axis deviation improved from 31.9 mm to 3.0 mm. The average amount of angular correction was 11.0degrees on tibiae and 10.0degrees on femora. The average length gain on femora was 6.4 cm, and the healing index averaged to 1.1 mo/cm. One patient underwent quadricepsplasty and one patient had three augmentation surgeries due to poor new bone formation. CONCLUSION: We believe that Dyna-ATC is a useful alternative to bulky ring fixators for selective patients with angular deformity less than 30 degrees in the coronal plane around the knee joint.

Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia

BACKGROUND: There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft. METHODS: Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated. RESULTS: All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively. CONCLUSIONS: Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.

Effects of Heat Shock and Antioxidant on the Growth Plate of Unloaded Rats / 대한정형외과연구학회지

PURPOSE: This study was performed to examine any histopathological changes occurring in the growth plate when the rats were subjected to be deprived of normal weight bearing using the hindlimb suspension model, and to search for any countermeasures for improving and/or recovering the chondrocyte activities within the growth plate. MATERIALS AND METHODS: Sixty male Sprague-Dawley rats, aged 6 weeks, were divided into 10 groups each: Group I-control to unloading; Group II-unloading 3 weeks only; Group III-unloading+application of heat shock; Group IV-unloading+application of antioxidant; Group V-unloading+application of heat shock and antioxidant; Group VI-control to reloading; Group VII-reloading 1 week only; Group VIII-reloading+application of heat shock; Group IX-reloading+application of antioxidant; Group X-reloading+application of heat shock and antioxidant. The animals were double labeled with 5-Bromo-2'-deoxydiuridin (BrdU) and BrdU immunohistochemistry was performed for the cellular kinetic analysis. Transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) assay was done for the investigation of apoptotic changes in the growth plate, and the positive cells were counted in each zones of the growth plate in both TUNEL and BrdU immunohistochemistry. Heat shock protein (HSP), indian hedgehog (Ihh), and vascular endothelial growth factor (VEGF) were immunolocalized to assess the chondrocytic activities in terms of production of extracellular matrix protein. RESULTS: Non-weight bearing induced a reduction of height of the growth plate, reduced cellular proliferation of chondrocytes, reduced expression of Ihh and VEGF, and altered expression of heat shock protein. When heat shock and/or antioxidant were applied to the unloaded and reloaded rats, only rats in the group of application of both heat shock and antioxidant showed normal cellular activities in terms of cellular proliferation and the production of extracellular matrix protein. CONCLUSION: The present results suggest that application of heat shock and antioxidant would be a countermeasure for the restoration of chondrocytic activities when the normal weight-bearing is deprived of.

Treatment of Femoral Shaft Fracture with Interlocking Humeral Nail in Older Children and Adolescent

PURPOSE: To evaluate the results of interlocking humeral nail for femur shaft fractures through the greater trochanter in older children and adolescent. MATERIALS AND METHODS: Eleven femoral shaft fractures in ten patients were selected. They were consisted of 9 boys and 1 girl. Two patients had osteogenesis imperfecta and one patient had a simple bone cyst as an underlying disease. 7 cases were right side and 4 cases were left side. The mean age at the time of operation was 12 years and 7 months (8 years 11 months~15 years 7 months). The mean follow-up period was 21 months and interlocking humeral nail was inserted at the greater trochanter in all patients. RESULTS: All patients had a complete bony union without any complication such as infection, nonunion, leg length discrepancy and metal failure. Avascular necrosis of femoral head and coxa valga were not developed in all patients. CONCLUSION: Intramedullary nailing through the greater trochanter using interlocking humeral nail is effective and safe treatment for the femoral shaft fracture in older children and adolescents.

Altered Synthesis of Cartilage-Specific Proteoglycans by Mutant Human Cartilage Oligomeric Matrix Protein

BACKGROUND: The mechanism by which mutant cartilage oligomeric matrix protein (COMP) induces a pseudoachondroplasia phenotype remains unknown, and the reason why a mutation of a minor protein of the growth plate cartilage causes total disruption of endochondral bone formation has not yet been determined. The current study was performed to investigate the effects of mutated COMP on the synthesis of the cartilage-specific major matrix proteins of Swarm rat chondrosarcoma chondrocytes. METHODS: The Swarm rat chondrosarcoma chondrocytes transfected with a chimeric construct, which consisted of a mutant gene of human COMP and an amino acid FLAG tag sequence, were cultured in agarose gel. Formation of extracellular proteoglycan and type-II collagen by the cells was evaluated by immunohistochemical staining and measuring the (35)S-sulfate incorporation. RESULTS: No difference was observed for the detection of type-II collagen among the cell lines expressing mutant COMP and the control cell lines. Histochemical staining of sulfated proteoglycans with safranin-O showed that lesser amounts of proteoglycans were incorporated into the extracellular matrix of the chondrocytes transfected with the mutant gene. (35)S-sulfate incorporation into the cell/matrix fractions demonstrated markedly lower radiolabel incorporation, as compared to that of the control cells. CONCLUSIONS: Mutation of COMP has an important impact on the processing of proteoglycans, rather than type-II collagen, in the three-dimensional culture of Swarm rat chondrosarcoma chondrocytes.

The First Korean Case of Camurati-Engelmann Disease (Progressive Diaphyseal Dysplasia) Confirmed by TGFB1 Gene Mutation Analysis

Camurati-Engelmann disease (CED) is an autosomal dominant progressive diaphyseal dysplasia caused by mutations in the transforming growth factor-beta1 (TGFB1) gene. We report the first Korean family with an affected mother and son who were diagnosed with CED. The proband is a 19-yr-old male with a history of abnormal gait since the age of 2. He also suffered from proximal muscle weakness, pain in the extremities, and easy fatigability. Skeletal radiographs of the long bones revealed cortical, periosteal, and endosteal thickenings, predominantly affecting the diaphyses of the upper and lower extremities. No other bony abnormalities were noted in the skull and spine and no remarkable findings were seen on laboratory tests. The patient's mother had a long-standing history of mild limb pain. Under the impression of CED on radiographic studies, we performed mutation analysis. A heterozygous G to A transition at cDNA position +653 in exon 4 of the TGFB1 gene (R218H) was detected in the patient and his mother.

In Situ Late Metaphyseal Osteosynthesis for the Fractures of the Lateral Humeral Condyle in Children

PURPOSE: To evaluate the efficacy of the in situ late osteosynthesis for slightly displaced fractures of the lateral humeral condyle. MATERIALS AND METHODS: From 2000 to 2004, 12 patients (8 boys and 4 girls) were managed with in situ late osteosynthesis for fractures of the lateral humeral condyle. The average age at the time of operation was 6 years 1 month (1 year 7 months~9 years 1 month), and the mean amount of fragment displacement was 3.3 mm (2.0~4.5 mm). The operative procedure included curettage and in situ fixation of the fragment RESULTS: Bony union was achieved in all cases after avg. 48 months (33~73 months) follow-up assessment. According to the score system of Dhillon et al, 7 patients had excellent, 3 had good, 2 had fair results. None of the patients developed avascular necrosis or premature closure of the epiphysis. CONCLUSION: We suggest that in situ fixation is an effective method for the late treatment of slightly displaced fracture of the lateral humeral condyle.

Use of Allograft in Skeletally Immature Patients for Calcaneal Neck Lengthening Osteotomy

PURPOSE: To date, there have been no studies evaluating the usefulness of allograft as a substitute for autograft in calcaneal neck lengthening osteotomy. This retrospective study examined the results of calcaneal neck lengthening osteotomy using allograft for pathologic flatfoot deformity in children and adolescents with various neuromuscular diseases. MATERIALS AND METHODS: 118 feet in 79 children treated surgically between Mar 2000 and July 2005 were reviewed. The mean age at the time of the operation was 9+3 years (range, 3-17 years) and follow-up averaged 15.4 months (range, 13-21 months) postoperatively. Talo-1st metatarsal angle, talo-calcaneal angle, calcaneal pitch were measured before and after operation and bony union was estimated. RESULTS: Bony union was noted at the latest follow-up and there were no postoperative complications such as reduction loss, infection, nonunion, delayed union or graft loss during the follow-up period in all but one foot. All radiographic indices were improved postoperatively in all cases. CONCLUSION: Our results indicate that use of allograft in calcaneal neck lengthening osteotomy is a useful option for correction of the planovalgus deformity in skeletally immature patients whose enough autobone can not be obtained.

The "Four-in-One" Procedure for Habitual Patellar Dislocation in Children with Formation Failure of Femoral Trochlea and Generalized Ligamentous Laxity : A Preliminary Report / 대한정형외과학회잡지

Purpose: To evaluate the clinical results of a "Four-in-One" procedure for a habitual dislocation of the patella in children with generalized ligamentous laxity and formation failure of the femoral trochlea. Materials and Methods: Five knees in 4 patients were included in this study. The average age of the patients at the time of surgery was 5.9 years and the subjects were followed up for an average of 41.6 months postoperatively. The clinical results were evaluated using the criteria of the Kujala's scoring system as well as a physical examination and radiological findings. Results: During the follow-up period, there were no recurrent dislocations, knee joint pain, limitations of motion or gait disturbances in any of the cases. The mean Kujala score was 96.8. Two cases had complications related to wound healing but they healed eventually. Conclusion: The "Four-in-One" procedure, which include the lateral retinacular release, medial vector augmentation, semitendinosus tenodesis, and patellar tendon transfer is recommended for a habitual dislocation of the patella in children with generalized ligament laxity and formation failure of the femoral trochlea.

Refractures of the Upper Extremity in Children

Purpose: To investigate the etiologic factors related to refractures of the upper extremity in children. Patients and Methods: Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity. Results: Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively. Conclusion: In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.

A New Classification for Idiopathic Genu Vara

PURPOSE: Past classification for the treatment of idiopathic genu vara depended simply on the measurement of distance between the knees, without attention to the rotational profile of the lower extremity. We retrospectively analyzed anatomical causes of idiopathic genu vara. PATIENTS AND METHODS: Twenty eight patients with idiopathic genu vara were included in this study. All patients were surgically treated. To evaluate the angular deformity, a standing orthoroentgenogram was taken and the lateral distal femoral angle and the medial proximal tibial angle were measured. In order to assess any accompanying torsional deformity, both femoral anteversion and tibial external rotation were measured using computerized tomographic scans. A derotational osteotomy was performed at the femur or tibia to correct rotational deformity, and a correctional osteotomy was performed at the tibia to correct angular deformity. RESULTS: Satisfactory functional results were obtained in all cases. Genu vara was divided into 3 groups according to the nature of the deformity; group 1 (6 patients) with increased femoral anteversion, group 2 (10 patients) with proximal tibial varus deformity alone, and group 3 (12 patients) with proximal tibial varus deformity accompanied by increased external tibial rotation. CONCLUSION: The success seen in our cases highlights the importance of an accurate preoperative analysis that accounts for both rotational and angular deformities that may underlie idiopathic genu vara.

Causes and Surgical Treatment of Idiopathic Genu Vara / 대한정형외과학회잡지

PURPOSE: To determine the underlying causes of idiopathic genu vara, and to evaluate the results of surgery. MATERIALS AND METHODS: Radiographic measurements were made using a standing orthoroentgenogram and a computerized axial tomography scan. Functional and cosmetic results after surgery were evaluated according to the causes. RESULTS: The patients with idiopathic genu vara were categorized into three groups: a group associated with increased femoral anteversion, a group associated with tibia vara and increased external rotation of the tibia, and a group associated with tibia vara. Satisfactory functional and cosmetic results were obtained after corrective surgery based on actual causes. CONCLUSION: An accurate analysis based on the rotational and angular deformities is needed to make a surgical treatment plan for idiopathic genu vara.

Tibialis Anterior Tendon Transfer for Calcaneus Deformity in Children with Myelomeningocele: A Preliminary Report / 대한정형외과학회잡지

PURPOSE: To examine the results of tibialis anterior tendon transfer for the treatment of a calcaneus deformity in children with a myelomeningocele. MATERIALS AND METHODS: Twenty-seven feet in sixteen children were examined in this study. The mean age at the time of surgery was 7(+2) years (range, 4(+11)-14(+9)) and the mean follow up duration was 25 months (range, 15-50). Three-dimensional gait analysis and dynamic foot-pressure measurement were performed to analyze the results of the index operation. RESULTS: There was no recurrence or aggravation of the deformity. The sagittal kinematics of the ankle improved, and the relative impulse of the calcaneus decreased postoperatively. Those patients with an increased range of motion of the pelvic rotation during gait showed less improvement in the relative impulse of the calcaneus than those with a good range of pelvic rotation. They also had a lower range of knee sagittal motion and an increased range of abduction of the hip, and up-obliquity of the pelvis. CONCLUSION: A good range of motion of the hip and pelvis in coronal and transverse planes, and of the knee in the sagittal plane are important predictors of the functional transfer of tibialis anterior tendon in patients with a calcaneal gait in a myelomeningocele.

A Comparison of Autologous and Homologous Transfusions in Spinal Fusion

Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.

A Comparison of Autologous and Homologous Transfusions in Spinal Fusion

Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.

Changes in Gait Pattern After Surgeries for Equinus Gait in Cerebral Palsy Spastic Hemiplegia / 대한정형외과학회잡지

PURPOSE: To evaluate the effects of surgery for an equinus gait on the kinematic and kinetic parameters of ankle and proximal joints in cerebral palsy spastic hemiplegics. MATERIALS AND METHODS: Sixteen spastic hemiplegic patients who had undergone a surgical correction for equinus were enrolled in this study. The kinematic and kinetic parameters during gait were assessed using computed gait analysis before and after surgery. RESULTS: Postoperatively, the ankle range of motion was significantly improved and the temporospatial parameters were not significantly changed. The angular movement of the ankle joint and pelvis were improved. However, the kinetic parameters of the ankle joint were unaffected. In patients with a recurvatum knee gait pattern prior to surgery, the kinematic and kinetic parameters of the knee joint were significantly improved. The angular movements of pelvis after surgery were improved in patients with pelvic external rotation preoperatively. CONCLUSION: Genu recurvatum and pelvic external rotation during the gait in spastic hemiplegic CP might be improved by a surgical correction of the equinus deformity.