Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure.

OBJECTIVE: The Pavlik harness (PH) has been widely used as the standard treatment for infants with developmental dysplasia of the hip (DDH). When the initial application of the PH fails, alternative treatments, such as closed reduction, open reduction, and reapplication of the PH will be considered. Compared with other treatments, reapplication of the PH offers certain advantages, including simplicity and reduced physical, and psychological stress, on both infants and caregivers. This study aims to investigate the effectiveness of reapplying the PH in patients with DDH. METHODS: This study included patients with DDH (complete dislocation) who were treated by reapplication of PH between 1988 and 2012. Patients who were able to follow-up for more than 5 years were included. We examined the reduction rate and several factors to identify indicators associated with successful reduction during reapplication, including age, sex, side of hip dislocation, and the presence of the Ortolani sign. At the final follow-up, hip development was assessed using the Severin classification, whereas avascular necrosis (AVN) was evaluated using the Kalamchi classification and the Salter criteria. RESULTS: A total of 56 patients (48 females and 8 males) and 57 hips were included in this study. The mean age at first and second application of PH was 4.2 months old (range: 0.12 to 6.4), and 5.8 months old (3.0 to 11.4), respectively. The reduction rate was 49% (28 out of 57 hips). Among the successfully reduced hips, the AVN rate was 3.6% (1 out of 28 hips). The Severin classification revealed 27 hips in class I and 1 hip in class III. Statistical analysis indicated a significantly higher proportion of left hip involvement in the reduction group (85% vs 41%, χ 2 test, P < 0.001). Although not statistically significant, the rate of positive Ortolani sign tended to be higher in the reduction group (61% vs 38%, χ 2 test, P = 0.06). CONCLUSION: The reapplication method demonstrated a 49% reduction rate and a low AVN rate of 3.6% in our study. It is worth considering for patients who fail the initial PH treatment, particularly in cases of left-side dislocation and a positive Ortolani sign during the initial application.

Radiologic Changes After 10 Years Postreduction in Developmental Dysplasia of the Hip Treated With Different Reduction Methods and Risk Factors for Osteoarthritis.

BACKGROUND: This study examined how radiologic indices at 10 years postreduction change over time and influence the final outcome through a comparative study of 3 reduction methods for developmental dysplasia of the hip, including the Pavlik harness, closed reduction, and open reduction (OR). METHODS: Patients treated from 1990 to 2000 for dysplasia of the hip and followed up for >20 years were included in this study. Radiologic indices at 10 years postreduction and final follow-up (average 24 years postreduction) were measured in the 3 groups. The relative joint space of <66% compared with the healthy side was defined as positive osteoarthritis (OA) at the final follow-up. The relationship between OA and factors such as age, sex, method of reduction, radiologic indices, and Severin and Kalamchi classifications at 10 years postreduction were examined. Clinical evaluation was performed using the modified Harris Hip Score; a score of ≥80 was defined as good performance at the final follow-up. RESULTS: Sixty-five patients (totaling 74 hips) were included. There were no significant differences in radiologic indices between the 10-year postreduction time and final follow-up. Excluding 9 bilateral patients, based on the relative joint space, 21% of the patients (13/56 hips), were positive for OA. Univariate analysis showed that the incidence of positive OA was significantly associated with OR and Kalamchi grade 4 at 10 years postreduction. The modified Harris Hip Score was 80 or higher in 90% of the cases at the final follow-up. CONCLUSIONS: No significant changes in hip morphology were observed at 10 years postreduction. The Kalamchi classification at 10 years postreduction and OR were significantly associated with the incidence of OA at the final follow-up. Therefore, patients who undergo OR and/or display Kalamchi grade 4 have a high risk of developing OA and would require individual instructions for their daily lives to prevent further progression of OA and longer follow-up. LEVEL OF EVIDENCE: Level Ⅲ-case-control study.

De novo heterozygous variants in KIF5B cause kyphomelic dysplasia.

Kyphomelic dysplasia is a heterogeneous group of skeletal dysplasias characterized by severe bowing of the limbs associated with other variable findings, such as narrow thorax and abnormal facies. We searched for the genetic etiology of this disorder. Four individuals diagnosed with kyphomelic dysplasia were enrolled. We performed whole-exome sequencing and evaluated the pathogenicity of the identified variants. All individuals had de novo heterozygous variants in KIF5B encoding kinesin-1 heavy chain: two with c.272A>G:p.(Lys91Arg), one with c.584C>A:p.(Thr195Lys), and the other with c.701G>T:p.(Gly234Val). All variants involved conserved amino acids in or close to the ATPase activity-related motifs in the catalytic motor domain of the KIF5B protein. All individuals had sharp angulation of the femora and humeri, distinctive facial features, and neonatal respiratory distress. Short stature was observed in three individuals. Three developed postnatal osteoporosis with subsequent fractures, two showed brachycephaly, and two were diagnosed with optic atrophy. Our findings suggest that heterozygous KIF5B deleterious variants cause a specific form of kyphomelic dysplasia. Furthermore, alterations in kinesins cause various symptoms known as kinesinopathies, and our findings also extend the phenotypic spectrum of kinesinopathies.

The relationship between gluteus medius and minimus muscle volumes and hip development in developmental dysplasia of the hip.

BACKGROUND: Several studies in adult hips have revealed the role of the gluteus medius (Gmed) and gluteus minimus (Gmin) muscles in maintaining the stability and centripetal force of the hip joint. Hip centripetality in developmental dysplasia of the hip (DDH) patients contributes to subsequent healthy hip development later in life. The purpose of this study is to investigate the relationship between Gmed and Gmin volume and centripetality of the hip in infant DDH patients. METHODS: We retrospectively enrolled 41 unilateral DDH patients (4 males, 37 females) who were treated by closed reduction from 2006 to 2016 and underwent magnetic resonance imaging at around 2 years old. Gmed, and Gmin volume was measured in magnetic resonance imaging. We defined both Gmin and Gmed together as hip abductor gluteus muscles (GMs; Gmed + Gmin). The muscle volume ratio of the affected side was calculated by dividing the GMs volume of the affected side by the contralateral side. Relationships between center-head distance discrepancy (CHDD) at 2 years old, and at 4-6 years old and GMs volume ratio were investigated by Pearson's correlation coefficient within the same patients. RESULTS: Mean age of closed reduction was 0.8 years old and mean age at MRI was 2.2 years old with a mean follow-up period of 3.7 years. Mean GMs volume in the affected side, contralateral side, and muscle volume ratio were 25.3 cm3, 27.0 cm3, and 0.94, respectively. GMs volumes were significantly higher in the contralateral side (p < 0.001). GMs volume ratio at 2 years old significantly correlated with CHDD at 4-6 years old (p < 0.05). CONCLUSION: GMs volume at 2 years old was found to be associated with later hip afferents. Promoting the healthy development of GMs by properly maintaining the infant's natural hip movement is important for the healthy hip development. LEVEL OF EVIDENCE: Level III.

Influence of different energy patterns on efficacy of radial shock wave therapy.

BACKGROUND: One of the mechanisms of the efficacy of extracorporeal shock wave therapy (ESWT) for impaired muscle coordination of limbs is the destruction of Acetylcholine receptors (AChRs) at neuromuscular junction. The highly increased density of AChRs can change the acoustic impedance, and this change of the acoustic impedance can be the reason that radial shock wave (rESW) destroy AChRs selectively. However, the relationship between applied energy of rESWs and the therapeutic efficacy remains unclear, although some studies compared the clinical efficacy of rESWT between high- and low-energy applications. This study aimed to compare the CMAP change among different energy and pulses of rESW application. METHODS: Male Sprauger-Dawley rats were used. A device that generates radial shock waves pneumatically, was used to apply the following six patterns of radial extracorporeal shockwaves in different energy flux densities and pulses to the right calf of each rat: 1, 8000 pulses at 0.045 mJ/mm2; 2, 4000 pulses at 0.09 mJ/mm2; 3, 2000 pulses at 0.18 mJ/mm2; 4, 4000 pulses at 0.045 mJ/mm2; 5, 2000 pulses at 0.09 mJ/mm2; 6, 1000 pulses at 0.18 mJ/mm2. Left calf muscles were considered controls. RESULTS: There was a significant reduction in CMAP amplitude between control and rESW-exposed muscles in the group applied 4000 pulses with EFD at 0.09 mJ/mm2 and the group applied 2000 pulses with EFD at 0.18 mJ/mm2. However, the group applied 8000 pulses with EFD at 0.045 mJ/mm2 and all groups which was exposed to total 180 mJ rESW application did not show a significantly decreased CMAP amplitude compared with the untreated side. CONCLUSIONS: Total energy and energy flux density correlate with a decrease in CMAP amplitude by rESW application. These findings could be availed by clinicians in actual clinical setting for the proper application of rESW.

Characteristics and diagnostic factors associated with fresh lumbar spondylolysis in elementary school-aged children.

PURPOSE: We often encounter elementary school-aged children with fresh lumbar spondylolysis and non-union of bone. They may have factors that impede healing, and treatment outcomes need improvement. The purpose of this study was to investigate elementary school-aged patients with fresh lumbar spondylolysis and to identify characteristics that can aid in prompt diagnosis and proper therapy. METHODS: We retrospectively compared the characteristics of fresh lumbar spondylolysis in elementary school-aged children with those of older patients. We included patients aged 6-18 years with lower back pain and evidence of bone marrow oedema of lumbar pedicles on magnetic resonance imaging (MRI). The elementary school-aged group (group E) included 100 patients aged 6-12 years, and the senior group (group S) included 251 patients aged 13-18 years. We recorded patient sex, duration of lower back pain, injured site (lumbar level, unilateral/bilateral), presence of contralateral pars defect with evidence of high signal change on MRI (short tau inversion recovery), presence of spina bifida occulta (SBO), and follow-up treatment interruption rate. RESULTS: One-third of the patients in group E were female, and there was an even smaller proportion of females in group S. L5 lumbar spondylolysis was more common in group E. The treatment interruption rate was lower in group E. L5 SBO and contralateral pars defect were more common in group E. CONCLUSION: L5 lumbar spondylolysis, L5 SBO, and contralateral pars defect were important diagnostic factors in elementary school-aged patients. Identification of these characteristics will aid in prompt diagnosis and proper therapy.

Extracorporeal shock wave treatment can selectively destroy end plates in neuromuscular junctions.

INTRODUCTION: This study assesses the effect of radial extracorporeal shock wave (rESW) exposure on neuromuscular transmission and neuromuscular junction (NMJ) morphology. METHODS: We applied 2,000 rESWs at 0.18 mJ/mm2 and a frequency of 15 Hz to the right calf of male rats, measured the compound muscle action potential (CMAP), and examined NMJ morphology using electron microscopy. Left calf muscles were used as controls. RESULTS: rESW exposure significantly reduced CMAP amplitude without delayed latency in exposed muscles compared with controls. All rESW-exposed muscles exhibited NMJs with irregular end plates. Mean interjunctional fold interval was significantly increased compared with controls. However, axon terminals and muscle fibers surrounding NMJs with irregular end plates were unchanged. DISCUSSION: This localized destruction of end plates may be caused by differences in acoustic impedance induced by the density of acetylcholine receptors. These results provide a possible mechanism for the effectiveness of rESW treatment for spasticity and dystonia. Muscle Nerve 57: 466-472, 2018.

Single Versus Combined Procedures for Severely Involved Legg-Calvé-Perthes Disease.

BACKGROUND: The concept of containment as an effective approach to reduce the risk of femoral head deformity has been questioned because modest results have been achieved after nonoperative and operative treatments for severely involved Legg-Calvé-Perthes disease. Several reports have shown the limited effectiveness of some conventional single procedures. However, there is limited data on the effectiveness of combined procedures. METHODS: The surgical group comprised 77 patients (mean age 8.3 y) and involved 79 hips. The average follow-up term was 9.5 years. Sixty-five patients were unilaterally involved and 12 patients were bilaterally involved (although 10 of the latter patients only received surgery on 1 hip). Among patients, 28 hips were classified as Herring class B/C border (>8 y old) and 51 hips were Herring class C. The 79 hips were divided into 2 treatment groups for further analysis: group 1, single procedures (femoral varus osteotomy) (n=47); group 2, combined procedures [femoral varus osteotomy+Dega (Pemberton) osteotomy] (n=32). RESULTS: Using Stulberg classification I and II (acceptable outcome), the final outcome was statistically significant for group 2 (21 hips, 65.6%) compared with group 1 (18 hips, 38.3%) (P=0.031). The average remodeling efficacy, defined as the change in caput index between preoperation and postoperation, was better in group 2 (12.7%) than in group 1 (3.9%) (P=0.005). The acetabulum-head index and α-angle were also statistically significant in group 2 than in group 1 at the last follow-up. Clinical evaluations were statistically significant in group 2 compared with group 1. CONCLUSIONS: Both clinically and radiologically, the combined procedure group demonstrated significantly better outcomes with accelerated remodeling in both the severely affected femoral heads and the acetabula compared with the single procedure group. With this procedure, we anticipate the increased likelihood of preventing or delaying coxarthroses in adulthood. LEVEL OF EVIDENCE: Level III-therapeutic study.

The epidemiology of developmental dysplasia of the hip in Japan: Findings from a nationwide multi-center survey.

BACKGROUND: It has been reported that the national incidence of developmental dysplasia of the hip (DDH) has decreased in Japan. This is because of prevention activities after birth since around 1970. However, cases of late-diagnosed DDH have still been noted in some children's hospitals. There has been no recent survey of DDH in Japan. The purpose of this study was to investigate the current epidemiology of DDH using a comprehensive nationwide survey. METHODS: A questionnaire was sent to orthopedic surgeons in 1987 facilities nationwide, who were asked to complete and return a survey card on each DDH patient treated between April 2011 and March 2013. RESULTS: A total of 783 (39%) facilities completed and returned the card. Of these, 79% reported no cases of DDH-related dislocation over the 2-year period, while the remaining facilities reported 1295 cases. The characteristics of children diagnosed with DDH-related dislocation were as follows: girls (89%), left side involvement (69%), bilateral involvement (4%), positive family history (27%), first-born (56%), and pelvic position at birth (15%). Seasonal variation showed an increase in DDH incidence among those born in the winter. Overall, 199 cases (15%) were diagnosed at >1 year of age, and these included 36 cases diagnosed very late, at >3 years of age. The majority of the 199 cases of late diagnosis had received earlier routine screening at <1 year of age. CONCLUSION: The characteristics of the children diagnosed with DDH nationwide were similar to past data from local regions. However, many children were diagnosed late (>1 year of age), particularly in the more populous regions. The findings identify a need for improved early routine screening for DDH in Japan.

Treatment for unstable slipped capital femoral epiphysis: Current status and future challenge in Japan.

BACKGROUND: Treatment for unstable slipped capital femoral epiphysis (SCFE) is challenging and controversial. For many years, the debate centered around closed treatments and especially the pros and cons of manual reduction and its concrete procedure. However, recent studies reported on open treatments such as open reduction through an anterior approach and modified Dunn procedure. Being in a period of such transition, we investigated the current status and future challenge of treatment for unstable SCFE. METHODS: A questionnaire survey of medical institutions specializing in pediatric hip disorders across Japan was conducted. Survey items were the accurate diagnosis of physeal stability, the pre- and intra-operative evaluation of epiphyseal hemodynamics, and current treatment strategy. RESULTS: Survey responses returned from 29 out of 40 participant institutions (response rate: 73%) revealed that 55% of the institutions evaluated physeal stability based on clinical findings of ambulation capability in accordance with the Loder classification. Another 38% diagnosed physeal stability comprehensively by combining the Loder classification and imaging findings. Epiphyseal hemodynamics was assessed preoperatively in 18% of the institutions, effectively using angiography, contrast-enhanced magnetic resonance imaging (MRI), and bone scintigraphy. Intraoperative assessment was performed in 13% based on the bleeding through a drilling hole on the articular surface and observation of the cancellous bone color during open surgeries. As a treatment strategy, 52% of the institutions used in-situ fixation, while another 38% used manual reduction and internal fixation. On the other hand, open reduction was used at 3 institutions (the remaining 10%): the modified Dunn procedure at 2 institutions and arthrotomy at 1 institution. CONCLUSION: Treatment for unstable SCFE remains controversial, but closed treatments without hemodynamic monitoring is no longer the center of the controversy. Today, the topic of the discussion is shifting toward how to correlate hemodynamic findings with treatment procedures and the indications for open treatments.

Outcome of patients with Legg-Calvé-Perthes onset before 6 years of age.

BACKGROUND: The prognosis of Legg-Calvé-Perthes disease (LCPD) in young patients has been accepted as favorable. The purpose of this study was to clarify the outcome of LCPD patients with onset before 6 years of age. METHODS: From 1989 to 2007, of 332 LCPD patients, 114 hips (in 100 patients) were diagnosed before 6 years of age (mean age, 4.5 y old) with subsequent repair of the epiphysis in all cases. Waldenström classification at presentation was initial stage in 76 hips and fragmentation stage in 38 hips. Lateral pillar classification was group A in 17 hips, group B in 22 hips, group B/C in 24 hips, and group C in 51 hips. Treatment methods were observation with restriction of activity alone in 42 hips and several containment treatments in 72 hips. RESULTS: At the mean age of 14, Stulberg classification was class I in 26 hips, II in 46 hips, III in 28 hips, and IV in 14 hips. These data show an acceptable outcome in 72 of 114 hips (63%). Logistic regression analysis revealed that lateral pillar classification (odds ratio, 3.6) and good range of abduction without treatment (odds ratio, 4.0) were prognostic factors. CONCLUSIONS: Poor outcome was observed even in patients before 6 years of age with large necrotic area. Lateral pillar classification and good range of abduction were prognostic factors. LEVEL OF EVIDENCE: Level IV. Therapeutic studies-investigating the results of treatment. Case series.

Lateral insertion is a good prognostic factor after in situ fixation in slipped capital femoral epiphysis.

BACKGROUND: In situ fixation (ISF) is standard treatment for slipped capital femoral epiphysis (SCFE) to stabilize the epiphysis and to prevent further slip. The aim of this study was to clarify the incidence of slip progression after ISF and its prognostic factors. METHODS: We retrospectively reviewed 53 hips in 49 consecutive SCFE patients who underwent single screw ISF and were followed until physeal closure. Clinical and radiographic findings were viewed to assess progression of the posterior tilting angle (PTA). RESULTS: Mean PTA was 33.4 degrees (range, 18 to 75 degrees) at ISF and 35.9 degrees (range, 18 to 75 degrees) at physeal closure with progression of PTA of 2.5 degrees (range, -2 to 19 degrees). Slip progression occurred in 28 of 53 hips (53%), and more than five degrees of progression occurred in 14 hips (26%). Multiple regression analysis revealed that point of screw insertion (one point for lateral and two points for medial) was a significant prognostic factor for progression of the slip by the following formula: (progression of PTA) = -1.523 + 2.701 × (point of screw insertion), R(2) = 0.148, p = 0.005. CONCLUSIONS: The current study showed that a screw inserted from the lateral side to the intertrochanteric line prevented postoperative slip progression.

Postoperative improvement of femoroacetabular impingement after intertrochanteric flexion osteotomy for SCFE.

BACKGROUND: Patients with slipped capital femoral epiphysis (SCFE) may develop cam-type femoroacetabular impingement (FAI). Early management of FAI has been advocated for patients with symptomatic FAI. The various treatment options, including reorientation surgeries, realignment procedures, and osteoplasty, remain controversial. QUESTIONS/PURPOSES: We asked whether an intertrochanteric flexion osteotomy improved the clinical symptoms of FAI in patients with SCFE and confirmed whether the radiographic signs were compatible with the clinical signs of FAI. METHODS: We retrospectively reviewed 32 symptomatic patients who underwent 32 intertrochanteric flexion osteotomies for severe SCFE. FAI was diagnosed clinically with a positive impingement sign. The osteotomies were designed preoperatively using CT. Cam-type FAI was evaluated with the modified α angle (ß angle) on a Lauenstein view, measured between the proximal femoral shaft axis and the line from the center of the femoral head to the anterior point where the distance of the head center exceeded the femoral head radius. The minimum followup was 2 years (mean, 5 years; range, 2-9 years). RESULTS: At last followup, only two patients complained of pain or inconvenience in daily life; the impingement sign was negative in 24 hips (75%). The ß angles at last followup were reduced on average by 39°. The postoperative ß angle was higher in hips with positive clinical signs of FAI than in those with negative signs. CONCLUSIONS: Intertrochanteric flexion osteotomy for SCFE improved the clinical and radiographic signs of FAI. The ß angle and clinical findings showed compatible improvement. We believe our intertrochanteric flexion osteotomy is a viable option for treating severe SCFE. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Sensory innervation of rat contracture shoulder model.

BACKGROUND: To date, few studies have investigated the cause of pain experienced by patients with frozen shoulder. The purposes of this study were to establish a rat contracture model and clarify the innervation pattern of the glenohumeral (GH) joint and subacromial bursa (SAB) using immunohistochemistry in the dorsal root ganglion (DRG) neurons. MATERIALS AND METHODS: The rat contracture models were made by tying the animal's humerus and scapula with No. 2-0 FiberWire (Arthrex, Naples, FL, USA). Contracture was confirmed on x-ray images taken 8 weeks after the operation. Subsequently, two kinds of neurotracers, Fluoro-Gold (FG) (Fluorochrome, Denver, CO, USA) and 1,1'-dioctadecyl-3,3,3',3'-tetramethyl-indocarbocyanine perchlorate (DiI) (Molecular Probes, Eugene, OR, USA), were used to detect the GH joints and SAB separately. FG tracers were injected into GH joints, and DiI tracers were injected into the SAB. At 7 days after injection, DRGs were harvested between C1 and T1. Immunohistochemistry by use of calcitonin gene-related peptide (CGRP) was performed. CGRP is thought to be one of the causes of pain sensation in joint disease. We evaluated the percentages of FG-labeled CGRP-immunoreactive (CGRP-ir) neurons in the total number of FG-labeled neurons and of DiI-labeled CGRP-ir neurons in the total number of DiI-labeled neurons. RESULTS: Abduction and total arc of the rotation were statistically significantly decreased in the contracture group. Furthermore, the percentage of CGRP-ir DRG neurons was significantly higher in the contracture group in both the GH joint and SAB. CONCLUSION: These results show that pain sensation in rat shoulder contracture may be induced by the up-regulation of CGRP expression in DRG neurons.

Natural history of popliteal cysts in the pediatric population.

BACKGROUND: Cystic mass lesions in the popliteal area, called popliteal cysts or Baker's cysts, are usually minimally symptomatic and not related to intra-articular morbidity in the pediatric population. Although multiple studies have described cases of spontaneous resolution over a period of several months to a few years, others still consider surgical treatment necessary. Furthermore, no previous studies have used magnetic resonance imaging (MRI) to confirm the disappearance of popliteal cysts. In this retrospective study, we reviewed records of patients with popliteal cysts to investigate the natural history of this disease. METHODS: The medical records of patients with popliteal cysts followed for at least 12 months were retrospectively reviewed. The patient set comprised of 17 knees in 15 males and 3 knees in 2 females. Mean age was 5.6±2.0 years (range, 1.8 to 11.4 y) at their initial visit to the clinic, and mean follow-up period was 53.1±31.6 months (range, 12.6 to 147.8 mo). MRI findings were reviewed for the 16 knees in 13 patients who had undergone MRI. Symptoms and clinical course were extracted from the medical records of all the study subjects and analyzed. RESULTS: Although 6 knees (30%) had histories of pain in the popliteal area, no patient complained of pain at their initial visit. Seventeen cysts (85%) naturally decreased in size or disappeared on clinical examination and/or ultrasound. Cysts confined to either the gastrocnemio-semimembranosus bursa or the subgastrocnemius bursa according to the MRI findings were classified as type I, and cysts which occupied both bursae were classified as type II. Eight knees received MRI examination more than once, and complete disappearance was confirmed in 5 of these knees. All type II cysts converted to type I, and all cysts which completely disappeared were type I before disappearance. CONCLUSIONS: The MRI findings in our study population confirmed that popliteal cysts in pediatric populations can be expected to completely resolve in due course without treatment. LEVEL OF EVIDENCE: Therapeutic study Level IV (Case series).

Athletic ability of school-age children after satisfactory treatment of congenital clubfoot.

BACKGROUND: This is the first study to objectively assess the athletic ability of school-age congenital clubfoot patients. METHODS: Forty-six feet of 30 patients (18 boys, 12 girls) were evaluated in this study. Nine patients were treated conservatively, 8 patients underwent percutaneous tenotomy of the Achilles tendon, and 13 patients were treated with extensive soft-tissue release. The mean age at the investigation was 9.2±1.9 years, and the mean follow-up period was 8.3±2.9 years. Athletic ability was evaluated by calculating Z-scores for the patients' scores in 5 physical fitness tests routinely performed nationwide at elementary schools: 50-meter run; standing long jump; repetition side steps; 20-meter shuttle run; and sit-ups. The Z-scores were calculated based on data published as the nationwide standards. RESULTS: Of the 148 scores recorded for the 5 tests for the 30 clubfoot patients, 143 scores (96.6%) were higher than the -2 SD value. The mean Z-scores were as follows: -0.32 for 50-meter run; -0.16 for standing long jump; -0.24 for 20-meter shuttle run; 0.22 for repetition side steps; and 0.06 for sit-ups. None of the events showed any significant differences among the three treatment groups. CONCLUSIONS: Congenital clubfoot with satisfactory treatment did not significantly impair the athletic performance. LEVEL OF EVIDENCE: Prognostic level III.

Anesthetic management of scapular Y-osteotomy using a combination of suprascapular nerve block and erector spinae plane block for Sprengel deformity associated with Klippel-Feil syndrome: a case report.

BACKGROUND: Klippel-Feil syndrome (KFS) occurs in 1/40,000 individuals and is characterized by cervical fusion. Thirty percent of patients with KFS present with Sprengel deformity, leading to orthopedic problems and limited shoulder abduction. No reports exist regarding anesthetic procedures for pediatric scapular osteotomies. CASE PRESENTATION: We report a case of a 4-year-and-7-month-old boy (95.6 cm, 14.7 kg) who underwent left scapular osteotomy. At the age of 8 months, he also underwent a right lower lobectomy due to a congenital pulmonary airway malformation. We decided to use a combination of suprascapular nerve block (SSNB), erector spinae plane block (ESPB), and general anesthesia. He received regular acetaminophen administration and fentanyl 5-10 µg/hour intravenously until 20 h postoperatively and remained on ≤ 2/10 in the Wong-Baker Face Scale (0: no hurt; 10: hurts worst). CONCLUSION: The combination of SSNB and ESPB could be an option for perioperative analgesia for scapular osteotomies.

Remodeling of angulation deformities in diaphyseal femoral fracture in children.

BACKGROUND: The purpose of this study was to reconsider the factors influencing the remodeling effects in diaphyseal femoral fractures in children based on radiological results. PATIENTS AND METHOD: We reviewed 39 patients with more than a 5° residual angulation deformity at the fracture site on anteroposterior and/or lateral views at the primary healing stage. The average follow-up period was 30.4 months. Angulation deformity was measured on plain radiographs both at the primary healing stage and the final follow-up. The correction rate (A - B/A × 100, A angulation deformities at the primary healing, B the angulation at the final follow-up) between at the primary healing stage and final follow-up was analyzed in terms of age at injury (0-5, 6-9, and ≥10 years), fracture site (proximal one third, middle one third, and distal one third) and direction of the deformities (coronal and sagittal planes). RESULT: The remodeling effect significantly appeared on the coronal plane (correction rate 66.7 %) rather than on the sagittal plane (correction rate 31.6 %) in the 0- to 5-year age group (P < 0.05). There was a statistically significant difference in the correction rate between the 0- to 5-year age group (66.7 %) and the 6- to 9-year group (30.6 %) on the coronal plane (P < 0.05), with no significance between any other two groups on both planes. No statistical difference of remodeling effect appeared among the three fracture sites. The average leg-length discrepancy was 4.7 mm longer. CONCLUSION: We suggest that a patient ≤5 years at injury could expect more sufficient remodeling on the coronal plane compared with the other age groups on both planes. However, a patient >5 years at injury should be encouraged to undergo the maximum possible correction of the angulation deformity at the initial treatment. Surgical intervention might be considered for that purpose.