Invasive pulmonary aspergillosis among patients with severe community-acquired pneumonia and influenza in ICUs: a retrospective cohort study.

RATIONALE: The prevalence, clinical characteristics, and outcomes of invasive pulmonary aspergillosis in patients with severe community-acquired pneumonia (CAP) in intensive care units remain underestimated because of the lack of a disease-recognition scheme and the inadequacy of diagnostic tests. OBJECTIVES: To identify the prevalence, risk factors, and outcomes of severe CAP complicated with invasive pulmonary aspergillosis (IPA) in intensive care units (ICUs). METHODS: We conducted a retrospective cohort study including recruited 311 ICU-hospitalized patients with severe CAP without influenza or with influenza. Bronchoalveolar lavage fluid (BALF) samples were from all patients and subjected to mycological testing. Patients were categorized as having proven or probable Aspergillus infection using a modified form of the AspICU algorithm comprising clinical, radiological, and mycological criteria. MEASUREMENTS AND MAIN RESULTS: Of the 252 patients with severe CAP and 59 influenza patients evaluated, 24 met the diagnostic criteria for proven or probable Aspergillus infection in the CAP group and 9 patients in the influenza group, giving estimated prevalence values of 9.5% and 15.3%, respectively. COPD and the use of inhaled corticosteroids were independent risk factors for IPA. IPA in patients with severe CAP was significantly associated with the duration of mechanical support, the length of ICU stay, and the 28-day mortality. CONCLUSIONS: An aggressive diagnostic approach for IPA patients with severe CAP and not only influenza or COVID-19 should be pursued. Further randomized controlled trials need to evaluate the timing, safety, and efficacy of antifungal therapy in reducing IPA incidence and improving clinical outcomes.

Protein phosphatase 6 activates NF-κB to confer sensitivity to MAPK pathway inhibitors in KRAS- and BRAF-mutant cancer cells.

The Ras-mitogen-activated protein kinase (MAPK) pathway is a major target for cancer treatment. To better understand the genetic pathways that modulate cancer cell sensitivity to MAPK pathway inhibitors, we performed a CRISPR knockout screen with MAPK pathway inhibitors on a colorectal cancer (CRC) cell line carrying mutant KRAS. Genetic deletion of the catalytic subunit of protein phosphatase 6 (PP6), encoded by PPP6C, rendered KRAS- and BRAF-mutant CRC and BRAF-mutant melanoma cells more resistant to these inhibitors. In the absence of MAPK pathway inhibition, PPP6C deletion in CRC cells decreased cell proliferation in two-dimensional (2D) adherent cultures but accelerated the growth of tumor spheroids in 3D culture and tumor xenografts in vivo. PPP6C deletion enhanced the activation of nuclear factor κB (NF-κB) signaling in CRC and melanoma cells and circumvented the cell cycle arrest and decreased cyclin D1 abundance induced by MAPK pathway blockade in CRC cells. Inhibiting NF-κB activity by genetic and pharmacological means restored the sensitivity of PPP6C-deficient cells to MAPK pathway inhibition in CRC and melanoma cells in vitro and in CRC cells in vivo. Furthermore, a R264 point mutation in PPP6C conferred loss of function in CRC cells, phenocopying the enhanced NF-κB activation and resistance to MAPK pathway inhibition observed for PPP6C deletion. These findings demonstrate that PP6 constrains the growth of KRAS- and BRAF-mutant cancer cells, implicates the PP6-NF-κB axis as a modulator of MAPK pathway output, and presents a rationale for cotargeting the NF-κB pathway in PPP6C-mutant cancer cells.

Classification of radial polydactyly based on physical characteristics.

BACKGROUND: Previous classifications in polydactyly of the thumb were by the level of duplication on radiography. This study aimed to develop a practical algorithm based on physical characteristics for treatment guidelines. METHODS: The polydactylies were stratified using four physical characteristics: floating, symmetry, dominant side, and joint angulation/nail size. The algorithm identified the hypoplastic type and then stratified the polydactylies as symmetric and asymmetric. The asymmetric type was divided into ulnar dominant and radial dominant. The symmetric type was divided into adequate type and inadequate type. The prediction of treatments was studied retrospectively by the distribution of surgical procedures in 500 patients with 545 affected thumbs, by the new classification and the Wassel-Flatt classification. RESULTS: Of the 545 polydactylies, 78 (14.5%) were categorized as the hypoplastic type, 369 (67.5%) as the ulnar-dominant type, 8 (1.5%) as the radial-dominant type, 70 (12.8%) as the symmetric adequate nail type, and 20 (3.7%) as the symmetric inadequate type. Treatments were excision and reconstruction in 403 polydactylies (73.9%), simple excision in 135 polydactylies (24.8%), and the Bilhaut-Cloquet procedure, ray amputation, and on-top plasty procedures were only performed in 7 polydactylies (1.3%). The distribution of surgical procedures was distinct among the new classification types and was similar among the Wassel-Flatt types. CONCLUSIONS: The new classification stratified polydactylies by physical findings in a stepwise manner. Though surgical technical details are not included, this simple classification is useful for paediatricians and parents to understand how a surgical decision is made. LEVEL OF EVIDENCE: Diagnostic Level IV.

Environmental factors associated with incidence of developmental dysplasia of the hip: a systematic review and meta-analysis.

BACKGROUND: Established associated factors for DDH include female sex, breech presentation, family history, congenital malformations, oligohydramnios, and maternal hyperthyroidism. However, evidence for environmental factors that may contribute to DDH is limited and inconsistent. METHODS: A systematic review of medical literature was conducted to collect data on environmental factors, including latitude, longitude, average yearly precipitation, average yearly temperature, minimum monthly temperature, and maximum monthly temperature, from all institutions that published articles on DDH. Univariate linear regression analysis was used to examine the correlation between environmental factors and DDH incidence, while multiple regression analysis was conducted to identify significant associated factors for DDH incidence. RESULTS: Data from a total of 93 unique manuscripts were analyzed, revealing a significant negative correlation between DDH incidence and temperature, including average yearly temperature (r = -0.27, p = 0.008), minimum monthly temperature (r = -0.28, p = 0.006), and maximum monthly temperature (r = -0.23, p = 0.029). Additionally, there was a significant positive correlation between DDH incidence and latitude (r = 0.27, p = 0.009), and a significant negative correlation between DDH incidence and average yearly precipitation (r = -0.29, p = 0.004). In the final multiple regression analysis, temperature, including average yearly temperature, minimum monthly temperature, and maximum monthly temperature, were identified as significant associated factors for DDH incidence. CONCLUSION: The findings of this study suggest an association between cold weather and DDH incidence. Further research should explore the link between cold weather and DDH incidence, offering insights into potential interventions for cold climates.

Soft Tissue Releases With Simultaneous Guided Growth Decrease Risk of Spastic Hip Displacement Recurrence.

BACKGROUND: Soft tissue release (STR) is an established treatment for spastic hip displacement, but recurrence of hip displacement is not uncommon. This study aims to (1) evaluate the recurrence of hip displacement after STR, (2) define associated factors of recurrence, and (3) elucidate the effects of guided growth on hip displacement recurrence. METHODS: The study subjects included 66 individuals with spastic cerebral palsy treated by STR with or without guided growth for hip displacement. The treatment goal was the maintenance of migration percentage (MP) to <40%. Recurrence was defined by a rebound of the MP by 5% or more after the first postoperative year. Children with recurrence were compared with those without recurrence using the Mann-Whitney U test and the χ 2 test. The risk factors for recurrence were evaluated using multiple logistic regression analysis. RESULTS: Nineteen individuals (29%) had a recurrence of hip displacement after the first postoperative year. They sustained a 2-fold increase in the rate of treatment failure ( P < 0.001) and reoperation ( P = 0.04). Age, sex, motor function, and preoperative radiographic parameters were comparable between individuals with and without recurrence. The use of guided growth was associated with less risk of recurrence than without (5% and 39%, respectively, odds ratio = 0.01 to 0.45, respectively) despite the similar risk of failure (35% and 48%, respectively, odds ratio = 0.15 to 4.82). CONCLUSIONS: Recurrence of the MP >5% after the first postoperative year is an important early indicator for failure to control MP to <40% and reoperation. Guided growth not only decreases coxa valga but also reduces the risk of recurrent hip displacement after STR. LEVEL OF EVIDENCE: Level III; case-control study.

Serum vascular endothelial growth factor affects tissue fluid accumulation and is associated with deteriorating tissue perfusion and oxygenation in severe sepsis: a prospective observational study.

BACKGROUND: Positive fluid balance and tissue fluid accumulation are associated with adverse outcomes in sepsis. Vascular endothelial growth factor (VEGF) increases in sepsis, promotes vascular permeability, and may affect tissue fluid accumulation and oxygenation. We used near-infrared spectroscopy (NIRS) to estimate tissue hemoglobin (Hb) oxygenation and water (H2O) levels to investigate their relationship with serum VEGF levels. MATERIAL AND METHODS: New-onset severe sepsis patients admitted to the intensive care unit were enrolled. Relative tissue concentrations of oxy-Hb ([HbO2]), deoxy-Hb ([HbR]), total Hb ([HbT]), and H2O ([H2O]) were estimated by near-infrared spectroscopy (NIRS) for three consecutive days and serum VEGF levels were measured. Comparisons between oliguric and non-oliguric patients were conducted and the correlations between variables were analyzed. RESULTS: Among 75 eligible patients, compared with non-oliguric patients, oliguric patients were administrated more intravascular fluids (median [IQR], 1926.00 [1348.50-3092.00] mL/day vs. 1069.00 [722.00-1486.75] mL/day, p < 0.001) and had more positive daily net intake and output (mean [SD], 1,235.06 [1303.14] mL/day vs. 313.17 [744.75] mL/day, p = 0.012), lower [HbO2] and [HbT] over the three-day measurement (analyzed by GEE p = 0.01 and 0.043, respectively) and significantly higher [H2O] on the third day than on the first two days (analyzed by GEE p = 0.034 and 0.018, respectively). Overall, serum VEGF levels were significantly negatively correlated with [HbO2] and [HbT] (rho = - 0.246 and - 0.266, p = 0.042 and 0.027, respectively) but positively correlated with [H2O] (rho = 0.449, p < 0.001). Subgroup analysis revealed a significant correlation between serum VEGF and [H2O] in oliguric patients (rho = 0.532, p = 0.003). Multiple regression analysis determined the independent effect of serum VEGF on [H2O] (standardized coefficient = 0.281, p = 0.038). CONCLUSIONS: In severe sepsis, oliguria relates to higher positive fluid balance, lower tissue perfusion and oxygenation, and progressive tissue fluid accumulation. Elevated serum VEGF is associated with worsening tissue perfusion and oxygenation and independently affects tissue fluid accumulation.

Prediction of Surgical Outcomes of Radial Polydactyly From the Wassel-Flatt Type and Symmetry of Duplication.

BACKGROUND: The Wassel classification is commonly used for cases of radial polydactyly but has not been used to predict surgical outcomes. This study aimed to investigate the predictive factors of surgical outcomes using the Wassel type and symmetry of duplication. METHODS: Forty-five patients with 47 radial polydactylies were reviewed using the Japanese Society for Surgery of the Hand (JSSH) scores 4.6 years after minor thumb excision and reconstructive surgery. The symmetry index was defined as the metaphyseal width ratio of the minor thumb to the dominant thumb. The relationships between the JSSH scores and operation age, sex, side, follow-up duration, Wassel type, symmetric index, divergent angle, and joint angulation were analyzed by linear regression. RESULTS: The mean JSSH score of the 47 thumbs was 18.3 points (range, 15-20). Five thumbs had fair or poor outcomes (scores <17), all of which were Wassel type IV. The hypoplastic type had a better JSSH score (19.4) than other Wassel types. The symmetric index had a negative relationship with JSSH scores, especially for Wassel type IV (r=-0.68, P =0.001). Linear regression revealed that the symmetric index was the only independent factor significantly associated with JSSH scores among Wassel type IV polydactylies ( P <0.05). The receiver operating characteristic curve suggested a symmetric index <0.74 could predict good or excellent outcomes. CONCLUSION: The symmetry of the 2 duplicated thumbs is an important factor for surgical outcomes. The Wassel type IV polydactylies with a symmetric index >0.74 are at greater risk of fair or poor outcomes after excision and reconstruction, and further studies are warranted to confirm whether the Bilhaut-Cloquet procedure is a good choice. LEVEL OF EVIDENCE: Level IV-Case-control study.

The impacts of bacterial co-infections and secondary bacterial infections on patients with severe influenza pneumonitis admitted to the intensive care units.

PURPOSES: This study investigated the prevalence and clinical outcomes of pulmonary bacterial co-infections and secondary bacterial infections in patients with severe influenza pneumonitis. METHODS: We retrospectively analyzed the data of adult patients with severe influenza pneumonitis admitted to medical ICUs. Bacterial co-infections and secondary bacterial infections were identified. The risk factors of bacterial infection were evaluated. The outcomes of patients regarding co-infection or secondary bacterial infection were analyzed. RESULTS: We identified 117 critically ill patients with laboratory-confirmed influenza pneumonitis admitted to the medical ICUs. Klebsiella pneumoniae (31.4%) and Staphylococcus aureus (22.8%) were the most identified bacteria in patients with bacterial co-infection. A high proportion of methicillin-resistant Staphylococcus aureus (17.1%) was noted. Liver cirrhosis and diabetes mellitus were the independent risk factors for bacterial co-infection. Acinetobacter baumannii (30.7%) and S. aureus (23.1%) were the most often identified bacteria in patients with secondary bacterial pneumonia. Patients with secondary bacterial infections had a longer duration of mechanical ventilation, and longer ICU and hospital stay. CONCLUSIONS: High rates of drug-resistant bacterial co-infections and secondary bacterial infections were identified in patients with severe influenza pneumonitis requiring ICU care and were associated with more morbidity in these patients.

Increased tissue water in patients with severe sepsis affects tissue oxygenation measured by near-infrared spectroscopy: a prospective, observational case-control study.

Background: Tissue oedema affects tissue perfusion and interferes with the monitoring of tissue oxygenation in patients with severe sepsis. However, the underlying mechanisms remain unclear. We used a wireless near-infrared spectroscopy (NIRS) device that transmits tri-wavelength light to quantify tissue haemoglobin (Hb) and water (H2O) content. We estimated tissue H2O in severe sepsis patients and healthy controls, compared their difference, and investigated the correlation of tissue H2O with systemic haemodynamics and its impact on tissue oxygenation. Methods: Seventy-seven adult patients with new-onset severe sepsis admitted to the intensive care unit within 72 h and 30 healthy volunteers (controls) were enrolled. The NIRS device was placed on the participant's leg to estimate the relative tissue concentrations of oxy-Hb ([HbO2]), deoxy-Hb ([HbR]), total Hb ([HbT]), and H2O ([H2O]) at rest for three consecutive days. Two-sample t-test or Mann-Whitney U test, chi-square test, and generalised estimating equations (GEEs) were used for comparisons. Results: In severe sepsis patients, the [H2O] in the anterior tibia was higher [mean (standard deviation, 95% confidence interval), 10.57 (3.37, 9.81-11.34) vs. 7.40 (1.89, 6.70-8.11)] and the [HbO2], [HbT], and tissue Hb oxygen saturation (StO2) were lower [0.20 (0.01, 0.20-0.20) vs. 0.22 (0.01, 0.22-0.23), 0.42 (0.02, 0.42-0.43) vs. 0.44 (0.02, 0.44-0.45), and 47.25% (1.97%, 46.80-47.70%) vs. 49.88% (1.26%, 49.41-50.35%), respectively] than in healthy controls in first-day measurements. GEE analysis revealed significant differences in [H2O], [HbO2], [HbT], and StO2 between groups over three consecutive days (all P≤0.001). In addition, [HbO2] and StO2 levels gradually decreased over time in the patient group. A negative correlation was observed between [H2O] and [HbO2] and StO2, which became more obvious over time (day 1: r=-0.51 and r=-0.42, respectively; both P<0.01; day 3: r=-0.67 and r=-0.63, respectively, both P<0.01). Systolic arterial pressure was positively related to [H2O] (r=0.51, P<0.05, on day 1) but was not associated with tissue oxygenation parameters. Conclusions: NIRS can be used to quantify tissue H2O. Severe sepsis patients have increased tissue H2O, which responds to changes in arterial blood pressure and affects tissue oxygenation.

Avascular Necrosis of the Hip Compromises Gait Balance Control in Female Juveniles With Unilateral Developmental Dysplasia Treated in Toddlerhood.

Avascular necrosis of the hip (AVN) is one of the most severe complications of surgical reduction when treating developmental dysplasia of the hip (DDH). The current study identified the differences in the balance control during walking in terms of the inclination angle (IA) of the center of pressure (COP) to the center of mass (COM), and the rate of change of IA (RCIA) between female juveniles with and without secondary AVN at the hip who were treated for unilateral DDH during toddlerhood as compared to their healthy peers. When compared to female healthy controls, the non-AVN group showed bilaterally similar compromised balance control with significantly decreased IA (p < 0.05) but increased RCIA (p < 0.04) in the sagittal plane during single-limb support (SLS) of the unaffected side, and in the frontal plane during terminal double-limb support (DLS) of the affected side. In contrast, the AVN increased between-side differences in the sagittal IA (p = 0.01), and sagittal and frontal RCIA during DLS (p < 0.04), leading to bilaterally asymmetrical balance control. Secondary AVN significantly reduced IA and RCIA in the sagittal plane (p < 0.05), and reduced range of RCIA in the frontal plane during initial DLS (p < 0.05). The trend reversed during terminal DLS, indicating a conservative COM-COP control in the sagittal plane and a compromised control in the frontal plane during body weight acceptance, with a compromised COM-COP control in the frontal plane during weight release. The current results suggest that increased between-side differences in the sagittal IA, and sagittal and frontal RCIA during DLS are a sign of AVN secondary to treated unilateral DDH in female juveniles, and should be monitored regularly for early identification of the disease.

Genu Valgum After Distal Femur Extension Osteotomy in Children With Cerebral Palsy.

BACKGROUND: Distal femur extension osteotomy (DFEO) is a common treatment for knee flexion contracture and crouch gait in patients with cerebral palsy (CP), but skeletally immature patients tend to develop genu valgum deformities after DFEO. This study aimed to report the tendency of valgus changes after DFEO and determine the risk factors for subsequent surgery for excessive genu valgum. METHODS: This retrospective case-control study included 25 children with CP who underwent DFEO in 44 limbs for knee flexion contractures ≥15 degrees at a mean age of 11.0 years. Radiologic measurements included the anatomic lateral distal femoral angle (aLDFA), anatomic tibiofemoral angle (aTFA), medial proximal tibia angle, and plate-condyle angle, postoperatively and at the latest follow-up. Age, sex, preoperative knee flexion contracture angle, Gross Motor Function Classification System level, and radiographic measurements were compared between children with and without subsequent guided growth for genu valgum. RESULTS: A significant valgus change was observed at the distal femur in the first postoperative year (aLDFA from 83.6 to 80.1 degrees, P<0.001; aTFA from 176.1 to 172.5 degrees, P<0.01; plate-condylar angle from 5.3 to 9.5 degrees, P<0.001). Valgus changes occurred in 36 of the 44 limbs (82%) by an average of -4.6 degrees in the aLDFA, and subsequent guided growth was performed in 5 patients (20%). Guided growth for genu valgum was associated with a greater postoperative valgus angle (aLDFA: 78.0 vs. 84.9 degrees, P<0.01) but not with age, Gross Motor Function Classification System level, or preoperative flexion contracture. CONCLUSIONS: Distal metaphyseal osteotomies and distally placed angled plates near the physis are associated with valgus changes following growth. We recommend making a slight varus alignment during DFEO to compensate for subsequent valgus changes. LEVEL OF EVIDENCE: Level III-therapeutic, retrospective comparative study.

Double diapering facilitates hip maturation in newborns.

BACKGROUND: Double diapering may help to maintain a baby's hips in flexion and abduction posture, but the efficacy in facilitating hip maturation has never been verified. We investigated whether double diapering results in greater improvement of the alpha angle in newborn babies. METHODS: This prospective study enrolled newborns with Graf type IIa immature hips and assigned them to the double-diaper or single-diaper group by the day of birth in a week. Parents were instructed on proper hip positioning, except for diapering. Change in the alpha angle from newborn to 1 month after birth, rate of improvement to bilateral Graf type I hips in 1 month, and number of ultrasound examinations and orthopaedic clinic visits in the first year were compared between the two groups. RESULTS: Seventy newborns with 102 type IIa hips were included from January to December 2017. They were allocated to the double-diaper group (n = 33) and single-diaper group (n = 37). With a comparable sex ratio, gestational age, and newborn alpha angle, the double-diaper group had a greater increase of alpha angles in 1 month than the single-diaper group (+7.9° vs. +5.2°, t-test, p = 0.011). Twenty-eight babies in the double-diaper group (84.8%) and 20 babies in the single-diaper group (54.1%) improved to having bilateral Graf type I hips (chi-square test, p = 0.006). Under the same clinical management pathway, subsequent clinical visits and hip ultrasounds before 1 year were significantly reduced in the double-diaper group. CONCLUSION: Double diapering enhances hip maturation and reduces clinical costs in newborns with physiological immature hips, but the therapeutic role for hip dysplasia requires further study.

Bilateral Asymmetry in Balance Control During Gait in Children with Treated Unilateral Developmental Dysplasia of the Hip.

INTRODUCTION: About 1% of the newborn population has developmental dysplasia of the hip (DDH), altering joint biomechanics, gait performance and balance control. Pemberton's osteotomy is used in early treatment but it remains unclear whether it will help the patient regain normal balance control during gait. The current study aimed to identify the changes of the whole-body balance control during level walking in children treated for unilateral DDH during toddlerhood, in terms of inclination angles (IA) of the line joining the body's center of mass (COM) and center of pressure (COP), and the rate of change of IA (RCIA). MATERIALS AND METHODS: Twelve girls (DDH group; age: 7.1 ± 2.1 years) who had been treated with Pemberton's osteotomy for unilateral DDH during toddlerhood and twelve healthy controls (Control group; age: 7.6 ± 2.1 years) walked at their preferred walking speed while IA, RCIA and temporal-spatial parameters were calculated from measured kinematic and forceplate data, and were compared using independent t-tests. RESULTS: Compared to the Control group, the DDH group showed significantly decreased sagittal IA (p = 0.042) but increased range of sagittal RCIA during SLS on the unaffected side (p = 0.006), and increased peak sagittal RCIA during DLS (p < 0.008). In the frontal plane, the altered COM-COP control occurred mainly during stance phase of the affected side, showing a decreased range of RCIA during SLS (p = 0.033) followed by decreased IA (p = 0.045) with an increased peak value of RCIA (p = 0.023) during terminal DLS. CONCLUSIONS: The children with treated unilateral DDH showed compromised, bilaterally different balance control strategies with altered COM-COP control during gait, not only during stance in the frontal plane as expected, but even more so during swing in the sagittal plane. It is thus suggested that routine assessment of the morphological changes and/or altered balance control of both the unaffected and affected hips is equally important for early identification of any signs of insidious hip problems, deteriorating balance control or increased risk of loss of balance.

Cold Weather as a Risk Factor for Late Diagnosis and Surgery for Developmental Dysplasia of the Hip.

BACKGROUND: Newborn hip screening aims to prevent the late diagnosis of and subsequent surgical procedures for developmental dysplasia of the hip (DDH). Weather may affect how parents swaddle their babies in early life, but weather has never been formally regarded as a risk factor in hip screening. This study investigates the association between the incidence of surgically treated DDH and the outdoor temperature. METHODS: Surgical procedures for late-diagnosed DDH were investigated in 12 birth-year cohorts (1999 to 2010) using the Taiwan National Health Insurance Research Database. The number of children who underwent a DDH-related surgical procedure between 6 months and 5 years of age per total live births was evaluated as an outcome of hip screening. Trend and regression analyses were used to determine the association between the incidence of surgically treated DDH and birth year, birth month, and the temperature during the birth month and first 3 months of life. RESULTS: The mean incidence of surgically treated DDH was 0.48 per 1,000 live births (1,296 surgically treated patients per 2,712,002 live births). The incidence of surgically treated DDH among babies born in winter months (0.70 per 1,000) was significantly higher than that among babies born in summer months (0.32 per 1,000), and it was significantly correlated with mean temperature in the first 3 months of life (r2 = 0.91; p < 0.0001) and birth month (r2 = 0.68; p < 0.001). Multivariable regression revealed that external temperature in the first 3 months of life was the most significant factor (ß = -0.034 [95% confidence interval, -0.042 to -0.022]; p < 0.001) for the incidence of surgically treated DDH (adjusted r2 = 0.485). The trend of seasonal differences remained the same throughout the study years following implementation of the hip-screening policy. CONCLUSIONS: As the incidence of surgically treated DDH is the ultimate outcome of newborn hip screening, cold weather should be regarded as a risk factor and should be incorporated into future screening programs. Weather patterns of different geographical areas should be studied to determine if children born in the winter are at an increased risk for requiring a surgical procedure for DDH, and newborn hip-screening programs should be revised accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Balance control and lower limb joint work in children with bilateral genu valgum during level walking.

BACKGROUND: Genu valgum results in lower limb malalignment and altered joint mechanics. The study aimed to identify the effects of genu valgum on balance control and muscular work at the joints during gait in children. RESEARCH QUESTION: Would bilateral genu valgum affect balance control and muscular work at the joints during gait in children? METHODS: Thirteen children with genu valgum and thirteen healthy peers walked at their preferred speed while the body's motions and ground reaction forces were measured to calculate the inclination angles (IA) and the rates of change of IA (RCIA) of the body's center of mass (COM) relative to the center of pressure (COP), as well as the muscular work done at the joints. An independent t-test was used to compare the variables between groups (α = 0.05). RESULTS: Compared to the controls, the patients showed significantly increased step width with altered frontal IA and RCIA variables (p < 0.05), including increased average IA over single-limb support and increased peak RCIA during double-limb support (p < 0.05). The patients significantly increased posterior RCIA at heel-strike but decreased anterior RCIA at toe-off (p < 0.05). The patients showed increased muscular work at both the hip and knee during single-limb support (p < 0.05). SIGNIFICANCE: The children with genu valgum showed a specific balance control strategy during gait. In the frontal plane, greater hip and knee muscular work was needed to maintain balance under an increased IA, likely owing to increased step width associated with the valgus alignment. In the sagittal plane, less smooth and less stable COM-COP control with increased RCIA at the key gait events indicates faster weight transfer between double-limb and single-limb support. It is suggested that patients with genu valgum, especially in more severe cases, should be monitored for signs of decreased ability and/or muscular strength in maintaining balance during gait.

Increased Loading Rates During Gait Correlate With Morphology of Unaffected Hip in Juveniles With Treated Developmental Hip Dysplasia.

Long-term follow-up studies on children with surgically treated developmental dysplasia of the hip (DDH) have shown that not only the affected side progresses to premature osteoarthritis, but the unaffected side may also suffer from insidious hip dysplasia or osteonecrosis. The current gait analysis study identified the loading and unloading rates of the ground reaction forces (GRF) and lower limb joint axial forces during gait, and their correlations with the hip morphology in twenty juvenile patients with surgically treated unilateral DDH during toddlerhood. In a gait laboratory, each subject walked at preferred speed on a 10-m walkway while the kinematics and the GRF were measured. Loading and unloading rates of the vertical GRF and the joint axial forces were obtained as the maximum instantaneous slope of these force curves. Radiographic measurements of the hips were taken, and the correlations between the morphological parameters and the loading and unloading rates were obtained. The patients showed greater-than-normal peak loading rates of the joint axial forces, and the loading rates on both the affected and unaffected sides were strongly correlated to the acetabular index on the unaffected side, which was also significantly correlated with the peak unloading rates on the affected side. These results suggest that apart from regular follow-up of the affected hip, routine assessment of the morphological changes and/or increased loading rates on the unaffected hip is also important for early identification of any signs of insidious hip dysplasia and risk of premature degeneration of the cartilage.

Tension band plates have greater risks of complications in temporary epiphysiodesis.

PURPOSE: This study aimed to compare the efficacy of decreasing leg-length discrepancy (LLD) and postoperative complications between tension band plates (TBP) and percutaneous transphyseal screws (PETS). METHODS: This retrospective study reviewed LLD patients who underwent temporary epiphysiodesis at the distal femur and/or proximal tibia from 2010 to 2017 (minimum two years follow-up). Efficacy of decreasing LLD was assessed one and two years postoperatively. Complications were classified with the modified Clavien-Dindo-Sink complication classification system. Knee deformities were assessed by percentile and zone of mechanical axis across the tibial plateau. RESULTS: In total, 53 patients (25 boys, 28 girls) underwent temporary epiphysiodesis (mean age, 11.4 years). The efficacy of decreasing LLD at two years between the TBP (n = 38) and PETS (n = 15) groups was comparable. Seven grade III complications were recorded in six TBP patients and in one PETS patient who underwent revision surgeries for knee deformities and physis impingement. Four grade I and two grade II complications occurred in the TBP group. The mechanical axis of the leg shifted laterally in the PETS group and medially in the TBP groups (+7.1 percentile versus -4.2 percentile; p < 0.05). Shifting of the mechanical axis by two zones was noted medially in four TBP patients and laterally in two PETS patients. CONCLUSION: More implant-related complications and revision surgeries for angular deformities were associated with TBP. A tendency of varus and valgus deformity after epiphysiodesis using TBP and PETS was observed, respectively. Patients and families should be informed of the risks and regular postoperative follow-up is recommended. LEVEL OF EVIDENCE: Level III.

Whole body balance control in Lenke 1 thoracic adolescent idiopathic scoliosis during level walking.

INTRODUCTION: Altered trunk shape and body alignment in Lenke 1 thoracic adolescent idiopathic scoliosis (AIS) may affect the body's balance control during activities. The current study aimed to identify the effects of Lenke 1 thoracic AIS on the balance control during level walking in terms of the inclination angles (IA) of the center of mass (COM) relative to the center of pressure (COP), the rate of change of IA (RCIA), and the jerk index of IA. The association between the Cobb angle, IA and RCIA was also evaluated. MATERIALS AND METHODS: Sixteen adolescents with AIS (age: 14.0±1.8 years, height: 154.8±4.7 cm, mass: 42.0±7.5 kg) and sixteen healthy controls (age: 14.4±2.0 years, height: 158.4±6.2 cm, body mass: 48.6±8.9 kg) performed level walking in a gait laboratory. The kinematic and ground reaction force data were measured for both concave-side and convex-side limb cycles, and used to calculate the IA and RCIA, the jerk index of IA, and the temporal-spatial parameters. Correlations between the Cobb angle, IA and RCIA were quantified using Pearson's correlation coefficients (r). RESULTS: The patients showed less smooth COM-COP motion with increased jerk index of IA in the sagittal plane during single limb support (SLS) of the concave-limb (p = 0.05) and in the frontal plane during double limb support (DLS) (p < 0.05). The patients also showed significantly increased posterior RCIA on both the concave and convex side during initial (p = 0.04, p = 0.03) and terminal (p = 0.04, p = 0.03) DLS when compared to healthy controls. In the frontal plane, the patients walking on the concave-side limb showed decreased IA over SLS (p = 0.01), and at contralateral toe-off (p<0.01) and contralateral heel-strike (p = 0.02), but increased mean IA magnitude over terminal DLS (p = 0.01). The frontal IA at contralateral toe-off and SLS for AIS-A showed a moderate to strong correlation with Cobb angles (r = -0.46 and -0.61), and the sagittal RCIA over the initial DLS for AIS-A also showed a significant, strong correlation with Cobb angles (r = -0.50). CONCLUSIONS: The patients with Lenke 1 thoracic scoliosis in the current study showed altered and jerkier COM-COP control during level walking when compared to healthy controls. During DLS, the patients increased the posterior RCIA in the sagittal plane with increased IA jerk index in the frontal plane for both the concave- and the convex-side limb, indicating their difficulty in maintaining a smooth transfer of the body weight. During SLS of the concave-side limb, the patients adopted a conservative COM-COP control strategy, as indicated by a decreased IA in the frontal plane, but showed a jerky COM-COP control in the sagittal plane. The COM-COP control of the patients was associated with the severity of the spinal deformity. The current results suggest that this patient group should be monitored for signs of an increased risk of loss of balance during weight transfer on the concave-side limb.