The relationship between hemoglobin-RDW ratio and clinical outcomes in patients with advanced pancreas cancer.

OBJECTIVE: The prognostic significance of hemoglobin (HGB) -red cell distribution width (RDW) ratio (HRR) has been indicated in various cancer types. However, its clinical significance in patients with metastatic pancreas cancer (MPC) is unknown. In this study, we aimed to investigate the prognostic importance of pre-treatment HRR in patients with metastatic pancreas cancer. PATIENTS AND METHODS: MPC patients (≥18 years of age) who received at least one course of chemotherapy between January 2001 and January 2021, were evaluated retrospectively in terms of pre-treatment HRR values. RESULTS: Of 111 patients, the mean HRR value was 0.84, and the patients were divided into low HRR and high HRR groups. The median follow-up was 8.7 months (95% CI 1.8-51.6). The median duration of first-line treatment was 4.4 months (95% CI 0.5-31.3). The median overall survival (OS) was 7.6 months (95% CI 3.4-11.8) in the low HRR group and 8.7 months (95% CI 5.7-11.8 months) in the high HRR group (p=0.276) (Figure 1). The median progression-free survival (PFS) was 4.2 months (95% CI 2.7-5.6 months) in the low HRR group and 5.1 months (95% CI 2.8-7.4 months) in the high HRR group (p=0.044) It was found that high HRR decreased progression event in both univariate (HR 0.67, 95% CI 0.45-0.99, p=0.046) and multivariate (HR 0.62, 95% CI 0.42-0.93, p=0.022) analysis. CONCLUSIONS: The present study emphasized that low HRR was a poor prognostic factor for PFS in patients with MPC. There was no statistically significant difference between the HRR groups regarding OS. This is the first study evaluating the prognostic significance of HRR in MPC.

Cancer information overload and death anxiety predict health anxiety.

OBJECTIVE: We aimed to investigate the relationship between health anxiety, cancer information overload and death anxiety in caregivers of inpatient cancer patients. PATIENTS AND METHODS: A total of 92 inpatient cancer patients' caregivers were included the study. A sociodemographic information form, Arabic Scale of Death Anxiety (ASDA), Health Anxiety Scale (HAS), Cancer Information Overload Scale (CIO) were given to participants to respond. RESULTS: Participants with high HAS scores were compared with those with low HAS scores; the rate of employed persons was less (n=16, 34.8% vs. n=30, 65.2%, p=0.006), income status was more likely to be very low/low (n=23, 50.0% vs. n=6, 13.0%, p<0.001) and research on cancer was more common (n=39, 84.8%, p<0.001). Median (IQR) CIO [24.0 (21.75-28.0) vs. 13.5 (11.0-18.25), p<0.001] and ASDA total [69.0 (62.0-77.0) vs. 41.0 (33.75-58.0), p<0.001] scores were higher in the group with high HAS score than in the group with low HAS score. Multivariate logistic regression analysis revealed that a moderate/high-income status [odds ratio (OR) 0.114, 0.013-0.986 95% confidence interval (CI), p=0.049], CIO score (OR 1.354, 1.106-1.658 95% CI, p=0.003) and ASDA total score (OR 1.079, 1.021-1.141 95% CI, p=0.007) were independent predictive factors for a high HAS score. CONCLUSIONS: Death anxiety and CIO are crucial determinants of health anxiety. More research in multi-dimensional design is needed to obtain additional information about the relationship between death anxiety, CIO and health anxiety.

Factors affecting prognosis and treatment strategies in metastatic soft tissue sarcomas: twenty years of experience.

OBJECTIVE: In this study, we aimed to reveal the general clinicopathological features, treatment features, and factors that could predict overall survival in metastatic soft tissue sarcomas, a very rare and heterogeneous disease group. PATIENTS AND METHODS: This study was a retrospective cohort study. Patients monitored with metastatic soft tissue sarcoma between January 2001 and January 2021 were evaluated retrospectively. Patients aged 18 years and over, histopathologically diagnosed with metastatic STS, and unsuitable for operations, such as local curative surgery or metastasectomy, were included in the study. RESULTS: A total of 179 patients in the metastatic stage and monitored in our center were included in the study. The median follow-up period was 8.4 months (IQR, 3.4-14.4). 58 (32.4%) patients were de-novo metastatic, and 121 (67.6%) patients developed metastasis later. The median age was 53.2 (Range: 18.8-87.6 years), and 101 (56.4%) patients were male. The most common primary location was the lower extremity (87) (48.6%). The most common histological subtypes were synovial sarcoma (38) (21.2%), pleomorphic sarcoma (37) (20.7%), and liposarcoma (26) (14.5%). The majority were grade 3 tumors (n=131, 73.2%). Having ECOG PS 2-3 (HR=2.829, 95% CI 1,667-4.800, p<0.001), having tumor grade as 3 (HR=1.748, 95% CI 1.150-2.656, p<0.009), receiving palliative chemotherapy (HR=0.294, 95% CI 0.144-0.600, p<0.001), and receiving two or more lines of chemotherapy among those palliative receivers (HR=2.505 95% CI 1.696-3.700, p<0.001) were independent predictive factors of mortality. CONCLUSIONS: Survival in metastatic soft tissue sarcoma is better in patients with good ECOG performance status, low tumor grades, and who have received palliative chemotherapy. Receiving more than one line of palliative systemic treatment for progressive disease improves survival.

Treatment options after regorafenib failure in metastatic colorectal cancer.

OBJECTIVE: In the treatment of metastatic colorectal cancer (mCRC), there is a need for a treatment option in patients who have received regorafenib (RGR) therapy and progressed, especially in patients fit enough to receive a new therapy. We aimed to compare the role of rechallenge chemotherapy (RCH CTx) with best supportive care (BSC) in mCRC patients after standard CTx and subsequent RGR treatment in terms of survival benefit. PATIENTS AND METHODS: Patients with progressive mCRC who received at least one month of subsequent RGR therapy after standard CTx treatments were included in the study. Patients were divided into two groups: receiving RCH CTx or BSC (without antitumoural therapy) after RGR failure. There were 26 patients in the RCH CTx group and 30 patients in the BSC group. The RCH CTx and BSC groups were compared for demographic and clinical features, laboratory parameters, and survival rates. RESULTS: After the RGR failure, the median overall survival (OS) for the RCH CTx (n = 26) and BSC (n = 30) groups were 7.5 (95% CI, 6.3-8.7) months and 1.2 (95% CI, 0.9-1.5) months, respectively (p < 0.001). The median OS was 7.5 (95% CI, 6.3-8.7) months for the RCH CTx (n = 26) and 1.4 (95% CI, 0.3-2.4) months for the BSC (n = 14) groups when only the patients with an Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≤ 2 at progression with RGR treatment were compared, respectively (p < 0.001). CONCLUSIONS: After the RGR failure, mCRC patients, especially those with a better ECOG-PS (≤ 2) and adequate organ function, should be considered candidates for RCH CTx instead of BSC.

Functional Role of Scroll Reconstruction in Open Rhinoplasty.

BACKGROUND: The scroll area of the nose is important for breathing; thereby, its reconstruction can improve the nasal patency. OBJECTIVE: To evaluate the effect of scroll reconstruction on breathing in patients following open rhinoplasty. METHODS: Using the prospective controlled study design, we enrolled a cohort of patients undergoing open rhinoplasty. The patients were randomly divided into two groups (each group with n = 14). The predictor variable was scroll reconstruction (yes/no). The main outcome variables include pre- and postoperative third-month peak nasal inspiratory flowmeter (PNIF) value (ml/min) and 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). Appropriate statistics were computed, and a P < 0.05 was considered significant. RESULTS: There was no demographic difference between both groups. Scroll reconstruction was associated with significantly improved PNIF post-surgery (P = 0.047). However, postoperative mean SCHNOS-O and SCHNOS-C was not different between the study and control groups (P = 0.58) CONCLUSIONS: This study suggests that scroll reconstruction helps improve nasal patency during forced inspiration in open rhinoplasty patients and provides a similar aesthetic outcome compared to the non-scroll-reconstructed group. Future research works should be done in a larger patient cohort. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The critical shoulder angle, the acromial index, the glenoid version angle and the acromial angulation are associated with rotator cuff tears.

PURPOSE: To compare the critical shoulder angle (CSA), acromion index (AI), acromion angulation (AA) and glenoid version angle (GVA) between patients with full-thickness rotator cuff tears (RCTs) and patients with intact rotator cuffs. METHODS: Between 2014 and 2018, the CSA, AI, AA and GVA were measured in consecutively included patients aged > 40 years who underwent shoulder arthroscopy for full-thickness RCTs. A total of 437 patients with RCTs and a mean age of 51.2 years (± 5.8) were included, 35.7% of whom were male. In the control group, there were n = 433 patients (36.3% male) with an intact rotator cuff, and the mean age was 50.7 years (± 5.3). RESULTS: The mean AI for the RCT group was 0.7 ± 0.1, which was significantly higher than the mean AI for the control group (0.6 ± 0.1, p < 0.001). The mean CSA for the RCT group was 33.6° ± 3.9°, which was significantly higher than the mean CSA for the control group (31.5° ± 4°, p < 0.001). The mean AA for the RCT group was 13.9° ± 9°, which was significantly higher than the mean AA for the control group (12.4 ± 8.6, p = 0.012). The mean GVA for the RCT group was - 3.5° ± 4.6° and significantly retroverted compared with the mean GVA for the control group (- 2.2° ± 4.6°, p < 0.001). The cutoff values determined by the ROC curve analyses were as follows: 0.6 for AI, 31.4° for CSA, 9.6° for AA and - 2.6° for GVA. CONCLUSION: The CSA, AI, GVA and AA values measured by MRI were determined to be significantly related to full-thickness rotator cuff ruptures. The AI, CSA, AA and GVA may be considered risk factors for degenerative rotator cuff tears. Assessing the CSA, AI, GVA and AA can be helpful for diagnostic evaluation of patients with full-thickness RCTs. LEVEL OF EVIDENCE: III.

Location of Femoral Vessels Around the Acetabulum in Crowe Type 4 Dysplastic Hips.

BACKGROUND: There are anatomical differences in the femur and acetabulum on the dysplastic hips. Yet, although there are detailed researches on bony structure differences, studies regarding anatomical differences for the vascular structure are insufficient. The study aimed to determine the relationship between the femoral artery and vein with acetabulum in computed tomography evaluation of Crowe type 4 hips and to compare with normal hip femoral vein and artery anatomic position. METHODS: Forty patients with one side hip Crowe type 4 deformity and opposite side normal hip were found suitable for the study. Pelvis CT was previously applied to all patients for the planning of total hip arthroplasty surgery. Normal hip acetabulum and the true acetabulum of the dysplastic hip were marked with the Ranawat's triangle and were then divided into quarters with four axial slices of the acetabulum; as dome, proximal one-fourth, center, and distal three-fourths. The shortest distance from the femoral vessels to the pelvis was measured at these 4 axial slices at the dysplastic side and compared with the healthy side. RESULTS: The distance of the vein to the acetabulum is closer to the dysplastic side. At distal three-fourths of Ranawat's triangle axial images, both femoral artery and femoral vein are closer to acetabulum at the dysplastic side. CONCLUSION: The analysis of preoperative images in cases of Crowe type 4 hip shows that the femoral vessels are closer to the anterior wall of the dysplastic true acetabulum at the level of the center of the hip (vein, mean: 2.7 mm closer) and below the center of the hip (vein, mean: 3 mm; and artery, mean: 3.3 mm closer) when compared with the normal acetabulum. Anatomic relationships knowledge can be used intraoperatively to avoid iatrogenic vascular injury during Crowe type 4 dysplastic hip arthroplasty surgery.

Protective effect of betaine against skeleton muscle apoptosis in rats induced by chronic alcohol and statin consumption.

AIM: The aim of the present study was to investigate the effect of apoptosis on rat skeletal muscle caused by chronic alcohol and statin consumption with modified liquid diet and to elucidate protective effects of betaine supplementation. METHODS: TNF-α (tumor necrosis factor), NF-kB (Nuclear Factor kappa B), cytochrome c and caspase-3 levels with or without betaine treatment in alcohol and/or statin-induced skeleton muscle apoptosis rats as well as in controls were measured in serum and tissue. Histologic examinations of the muscle tissues were also performed. RESULTS: In our study, betaine treated treatment groups we found that calpain and caspase activities and cytokine c release were decreased caused by alcohol, statin and more importantly alcohol+statin group and TNF and NF-kB levels were also close to the levels of control group. Similarly, significant improvements have been observed in our morphological and histological examination results also supporting our biochemical data. CONCLUSION: We found that combined consumption of ethanol and statin is capable of triggering apoptotic cell death in rat muscles more than the consumption of only alcohol or only statin. Betaine was able to reduced this muscle cell death induced by alcohol and/or statin consumption (Tab. 4, Fig. 4, Ref. 43).

Valgus Hip Osteotomy in Children With Spondyloepiphyseal Dysplasia Congenita: Midterm Results.

BACKGROUND: Coxa vara has been frequently reported in spondyloepiphyseal dysplasia congenita (SEDC), and proximal femoral osteotomy has been described as a useful treatment. The aim of this study was to discuss the clinical, radiographic, and gait outcomes after valgus extension osteotomy of the proximal femur. Changes of lumbar lordosis, associated with coxa vara correction, are reported as well as the outcome differences between different ages. METHODS: Records of children with SEDC, who were followed at our institution between 2004 and 2014, were reviewed; and children had hip surgery were identified. Hip pain and passive range of motion, radiographic neck shaft angle (NSA), and Hilgenreiner trochanteric (H-T) angle, sagittal spinopelvic parameters, and gait data were recorded. Preoperative and last follow-up data were compared. Outcomes were also compared between 3 age groups. RESULTS: Of the 79 children with SEDC, 26 children (12 boys and 14 girls) had hip osteotomy in 48 hips. Mean age at surgery was 9.6 years and the mean follow-up was 5 years. Preoperative hip pain was noted in 30 hips. At the last follow-up, 3 hips were painful at the extreme range of motion. Passive range of motion, NSA, and H-T improved postoperatively. Although NSA was maintained over the follow-up, H-T deterioration was noted. Spinopelvic measurements changed significantly and gait data remained stable except pelvic tilt that reduced significantly after surgery. The changes of radiographic measurements in each age group were similar to the total group of patients. CONCLUSIONS: In children with SEDC, surgical correction of coxa vara, by proximal femoral valgus osteotomy, is an effective treatment that improves hip pain and range of motion in addition to the radiographic alignment of the proximal femur and the sagittal spinopelvic alignment. Children are expected to maintain their level of function after surgery and to have good results over the midterm regardless of their age at surgery. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Tibial tubercle-trochlear groove distance and angle are higher in children with patellar instability.

PURPOSE: The purpose of this study was to assess the variations in tibial tubercle-trochlear groove distance and angle as a function of age and gender in a population of children without patellar instability (PI) compared with those with PI. METHODS: A retrospective review of 869 children's knee MRIs, ages 5 to 15 years, were evaluated using a control group (792 children) without evidence of PI and a group with PI (77 children). Tibial tubercle-trochlear groove distance (TT-TGd) and angle (TT-TGa) were measured twice by two readers to assess intra- and inter-observer reliability and compared between PI and control groups. In both groups, functions of age and gender on TT-TGd and TT-TGa values were evaluated. RESULTS: Both TT-TGd and TT-TGa measurements showed excellent intra- and inter-observer reliability. The mean TT-TGd for the PI group was 17.2 mm (SD 6.6) and significantly higher than the mean TT-TGd for the control group (10.4 SD 3.8 mm, P = 0.001). The mean TT-TGa for the PI was 20.8° (SD 8.3°), which was also significantly higher than the mean TT-TGa for the control group (12.5° SD 4.6°, P < 0.001). Control group revealed a positive correlation between age and TT-TGd measurements (r = 0.243, P < 0.001). The mean TT-TGa for girls (13.3° SD 4.7°) was higher than the mean TT-TGa for boys (11.9° SD 4.4°) in the control group (P < 0.001). CONCLUSION: TT-TGa and TT-TGd are reliable and can be used for the evaluation of the extansor mechanism alignment in children with and without PI. However, it must be considered that TT-TGd is increasing in growing patients. Soft-tissue procedures may be prone to failure, since bony procedures for patellar alignment cannot be done until skeletal maturity. LEVEL OF EVIDENCE: III.

The Effect of Previous Hip Surgery on the Outcome of Hip Arthroplasty in Young Patients.

BACKGROUND: The incidence of total hip arthroplasty (THA) is increasing in all age groups, especially in young patients. The outcome of THA is believed to be affected by morphological deformities created by previous pelvic or femoral procedures performed in childhood. The aim of the present study was to assess whether previous hip surgery impaired the functional outcome in young patients who underwent THA. METHODS: Data were collected from the records of patients aged less than 30 years who had undergone THA between 2002 and 2011. Thirty-five patients (44 hips) were included. The Western Ontario and McMaster Universities Osteoarthritis Index and Harris Hip Scores were collected as primary functional outcome measures. The secondary outcome measures were the major and minor complications. Patients were divided into 2 groups: those who had not undergone hip surgery before THA (group I, 17 patients, 24 hips) and those with a history of prior hip surgery (group II, 18 patients, 20 hips). RESULTS: The mean age at the time of surgery was 25 ± 4 years in group I and 23 ± 4 years in group II. The mean Harris Hip Score was slightly higher in group I (90 ± 7) than in group II (87 ± 7) (P = .2). The mean Western Ontario and McMaster Universities Osteoarthritis Index scores were similar in both groups (in group I 14 ± 7 and in group II 14 ± 6, P = .9). Complication rates were also similar in both groups (P = .7). CONCLUSIONS: It is often difficult to decide whether to perform THA in young patients. One potential risk factor for complications is hip surgery before THA. Our study revealed that young patients with or without a history of previous hip surgery achieved satisfactory functional outcomes with similar complication rates after THA.

Evaluation of A Well-Known Technique with Ultrasound: Dorsal Grafting in Rhinoplasty.

OBJECTIVE: We aimed to evaluate the survival of a well-known camouflage technique using ultrasound imaging of the graft through the nasal dorsum and supratip. MATERIAL AND METHOD: Twenty-two patients (8 women and 14 men) who underwent primary rhinoplasty performed by the same surgeon in Isparta, Turkey, between December 2013 and February 2015, were evaluated in this retrospective study. We used the remaining pieces of harvested septal cartilage during rhinoplasty as autologous graft material and venous blood mixture as a scaffold in a Turkish Delight fashion. We used a 10- to 14-MHz broadband linear ultrasound probe (Toshiba Aplio MX ultrasound system, Toshiba Medical Systems, Tustin, California). The mean total skin thickness values through bone (nasal dorsum) and cartilage (upper lateral cartilage) were calculated for each patient. Data were recorded for statistical analysis. We evaluated the patients pre- and postoperatively on the seventh day, first month, sixth month, and just before the end of the first year using ultrasonography. We made detailed ultrasonographic images of the skin and the underskin through the bone sculpture and compared the measurements. All patients were scanned at the same time of day to exclude diurnal variation of dermal edema. Patients who presented for primary functional rhinoplasty were included in the study. RESULTS: Nasal dorsum cartilage was significantly thicker on the seventh postoperative day, but the difference was not statistically significant in the sixth month after surgery compared with baseline values. There was no statistically significant difference between preoperative measures and measures in the sixth month. The difference in supratip thickness was significantly greater on the seventh postoperative day, and there was a large difference at the first month compared with preoperative values, but this did not reach significance. There was no significant difference in supratip thickness between pre- and postoperative values at the sixth month. CONCLUSION: This method can be easily performed to reduce visual and tactual irregularities on the dorsum of the nose and can promote perfection on the dorsal esthetic line, but it is not sufficient for augmentation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association of Skin Thickness With Alar Base Reduction in Patients Undergoing Lateral Crural Repositioning and Strut Grafting.

IMPORTANCE: Knowing the operation plan is important for rhinoplasty surgeons to prevent unpredictable results. OBJECTIVES: To investigate the frequency of alar base resection in patients with different skin thickness who underwent lateral crural repositioning and lateral crural strut graft and to evaluate the results in the context of the current literature. DESIGN, SETTING, AND PARTICIPANTS: This retrospective case series study included 621 patients who underwent primary open septorhinoplasty by the same surgeon between January 1, 2012, and June 30, 2015. From the surgical notes, operation type (lateral crural repositioning [LCrep] with lateral crural strut grafting [LCSG] and with or without alar base resection) and skin type were recorded. Study participants' skin types were determined intraoperatively and divided into 3 groups: (1) thick skin (the tip definition was limited by skin thickness and subcutaneous tissue), (2) thin skin (the tip cartilage was visible and could be observed despite overlying soft tissue and skin), and (3) normal skin (the tip cartilage during the procedure had no effect on the tip definition). MAIN OUTCOMES AND MEASURES: The rate of alar base resection according to the type of operation performed and patient skin thickness. RESULTS: Of the 621 patients in the study, 95 (15.3%) were men and 526 (84.7%) were women. Lateral crural repositioning with LCSG was performed in 319 surgical procedures (51.4%), and alar base reduction was performed in 329 (53.0%). The rate of alar base resection differed significantly on the basis of whether LCrep with LCSG was performed (odds ratio [OR], 1.82; 95% CI, 1.32-2.50; P < .001). In patients with thin skin, there was no significant difference in the incidence of alar base resection associated with LCrep with LCSG (OR, 2.034; 95% CI, 0.912-4.539; P = .08). In patients with thick skin, a significant difference in the frequency of alar base resection was associated with the application of LCrep with LCSG (OR, 1.995; 95% CI, 1.228-3.241; P = .005). In patients with normal skin, LCrep with LCSG had no significant association with the frequency of alar base resection (OR, 1.557; 95% CI, 0.930-2.607; P = .09). CONCLUSIONS AND RELEVANCE: The necessity of alar base reduction after LCrep with LCSG is greater in patients with thick skin than in patients with thin and normal skin. This study is the first to our knowledge to examine this topic in rhinoplasty. LEVEL OF EVIDENCE: 3.

Comparing Percutaneous Physeal Epiphysiodesis and Eight-Plate Epiphysiodesis for the Treatment of Limb Length Discrepancy.

BACKGROUND: Either percutaneous or eight-plate epiphysiodesis have been shown to be effective growth modulation techniques for the treatment of limb length discrepancies (LLD). However, few studies compared the outcomes of both techniques with some confounding results. The aim of this study was to evaluate the outcomes of the both techniques in the treatment of the LLD. METHODS: Between 2004 and 2012, medical records of all cases that underwent either eight-plate or percutaneous epiphysiodesis (PE) were reviewed. Age at surgery, sex, diagnosis, surgical site (proximal tibia/distal femur), time of follow-up, complications, and additional procedures were noted. Correction of the LLD was evaluated to calculate the rate of correction and the percentage of improvement from the long-leg standing x-rays or scanograms, collected at each visit. RESULTS: There were 24 patients in the eight-plate (10 girls and 14 boys) and 48 patients in the PE group (28 girls and 20 boys). No statistically significant difference was found in the age, sex, preoperative LLD, or follow-up between groups. Both groups reached to an average LLD below 2 cm. The percentage of improvement was significantly higher in the PE group (P=0.031). The rate of individual femoral and tibial correction did not differ between the groups. CONCLUSIONS: Both methods are shown to be effective for LLD correction. However, PE led to greater improvement during the same follow-up time with fewer complications and less need for additional surgical procedures.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from -26±17 degrees (E0, external negative) to -16±16 degrees (E1) and relapsed to -23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. LEVELS OF EVIDENCE: Level IV-therapeutic study.

Long-term Outcome of External Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: Internal tibial torsion (ITT) is a common boney deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome after external TDO performed to correct ITT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ITT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing the subjects mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, preop MTR (at E0), preop gait velocity (at E0), gross motor function classification system score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 36 legs (with E0 and E2) and 17 legs (with E0, E1, and E2). The mean age at surgery was 7.4±2.8 (range, 4 to 16.6) years. Comparing the changes over time, kinematic MTR improved from 17±11 degrees initially (E0) to -10±14 degrees short term (E1) and progressed to -23±13 degrees long term (E2) (P<0.05 E0/E1/E2; internal rotation is positive). At E2, 16 legs (44%) were found to be in the kinematic corrected group and 20 legs (56%) in the kinematic overcorrected group. There were no significant differences between the corrected and overcorrected groups of children in respect to age of surgery, gross motor function classification system, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although external TDO is an accepted form of treatment in children with CP, in the long term a tendency to move into external tibial torsion is common. Therefore, caution is warranted with children who initially present with ITT to avoid overcorrection. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Hallux valgus deformity correction without fusion in children with cerebral palsy.

This study aimed to evaluate the outcomes of nonarthrodesis surgical treatment of hallux valgus (HV) deformity in children with cerebral palsy using radiographic and gait analysis parameters. There were 25 patients who had hallux valgus correction in 39 feet. The mean age at surgery was 15±2.8 years and the mean follow-up duration was 14.6 months. The first metatarsal osteotomy was performed in nine feet, bunionectomy in 25 feet, and Aiken osteotomy in 32 feet. None had metatarsophalangeal joint fusion. We observed a significant correlation between HV correction and other foot and ankle gait parameters. Our study showed correction of HV deformity at short-term follow-up without fusion of the metatarsophalangeal joint. LEVEL OF EVIDENCE: Level IV Therapeutic Studies.

Comparison of Salter osteotomy and Tonnis lateral acetabuloplasty with simultaneous open reduction for the treatment of developmental dysplasia of the hip: midterm results.

The aim of this study was to compare the midterm clinical and radiological outcomes of the Salter osteotomy (SO) and Tonnis lateral acetabuloplasty (TLA) with concomitant open reduction for the treatment of developmental dysplasia of the hip. Twenty-five hips of 20 patients who underwent SO with open reduction and 26 hips of 23 patients who underwent TLA with open reduction were evaluated retrospectively. The average age of the patients at the time of the operation was 35.6 months in the SO and 36.6 months in the TLA group, without a statistically significant difference (P=0.836). The average follow-up times in the SO and TLA groups were 59.9 and 54.8 months, respectively (P=0.397). Preoperative (40.6° in the SO vs. 42.2° in the TLA, P=0.451) and last follow-up acetabular index (12° in the SO vs. 14° in the TLA, P=0.227) and center-edge angle measurements (30° in the SO vs. 26° in the TLA, P=0.069) did not show a statistically significant difference between the SO and TLA groups; however, early postoperative acetabular index improvement was better in the TLA group than in the SO group (21.2° in the SO vs. 17.2° in the TLA, P=0.014). According to the Severin grading system, both groups showed a similar number of good outcomes without a statistically significant difference (P=0.936). Clinical assessment on the basis of McKay's criteria showed similar good and excellent outcomes (P=0.936). Both osteotomy techniques showed similar satisfactory outcomes for the treatment of DDH in patients older than 18 months of age.