Introduction. Femoral-shortening osteotomy for the treatment of leg length discrepancy is demanding technique. Many surgical technique and orthopaedic devises have been suggested to perform this procedure. Herein, we describe modified femoral shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique. Materials and Methods. We operated on six patients with LLD. Mean femoral shortening was 4.2 cm. Osteotomy was performed using a multiple drill-hole technique, and bone was stabilized using an intramedullary nail. Post-operative clinical and radiological data were reported. Results. Shortening was achieved, with a final LLD of < 1 cm in all patients. All patients considered the lengths of the lower limbs to be equal. No special surgical skills or instrumentation were needed. Intraoperative and post-operative complications were not recorded. Conclusions. Percutaneous femoral-shortening osteotomy over a nail using multiple drill-hole osteotomy technique was effective and safe in treating LLD

This prospective, longitudinal study documents the muscle strength and baseline function of 18 patients undergoing closed femoral shortening for discrepancy in limb length. Patients were studied for two years following surgery. Function was measured by a self-reported questionnaire, timed tests of performance and measurements of muscle strength and power. After two years, the self-reported function and ability to complete timed functional tests had returned to or improved on the pre-operative values. Muscle strength remained slightly below the pre-operative value and was more marked in the quadriceps than the hamstrings. This study suggests that small decreases in muscle strength and power following closed femoral shortening do not adversely affect the patients’ ability to perform everyday activities

Background. Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Patients and Methods. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups. Results. The preoperative flexion of patients without iliofemoral osteoarthritis was significantly higher than for patients with iliofemoral osteoarthritis. All hips without iliofemoral OA had higher motion. The preoperative flexion in the higher motion group both with and without iliofemoral OA was significantly greater than in the lower group with iliofemoral OA (Figure 1). Leg length change in patients without iliofemoral osteoarthritis was significantly greater than with iliofemoral osteoarthritis (Figure 2), and the higher hip motion group had greater leg length change in THA than the lower motion group. No clinical evidence of postoperative neurologic injury was observed in patients with iliofemoral OA. Postoperative transient calf numbness in the distribution of the sciatic nerve was observed in 2 of 25 hips without iliofemoral OA (8.0%), however, no sensory and motor nerve deficit was observed. Discussion. The authors hypothesized that preoperative hip motion could affect soft tissue contractures, and our findings suggest that the soft tissues surrounding the hip joint with iliofemoral OA should be more contracted than the hip without OA. We also found leg length change in the higher motion group was greater than in the lower motion group. Previous studies reported limb lengthening in excess of 4 cm could increase the risk of nerve palsy. Transient calf numbness in the distribution of the sciatic nerve was observed in 2 hips without iliofemoral OA and their leg length change was not greater than 4 cm. Our findings suggest that hips without iliofemoral OA should be paid attention to protect the nerves from excessive elongation. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia

Introduction. The anatomic abnormalities are observed in developmental dysplasia of the hip (DDH) and it is challenging to perform the total hip arthroplasty (THA) for some DDH patients. If acetabular cup was placed at the original acetabular position in patients with high hip dislocation, it may be difficult to perform reduction of hip prosthesis because of soft tissue contracture. The procedures resolving this problem were to use femoral shortening osteotomy, or to place the acetabular cup at a higher cup position than the original hip center. Femoral shortening osteotomy has some concerns about its complicated procedure, time consuming, and risk of non-union. Conversely, implantation of the acetabular cup at the higher cup position may eliminate these shortcomings and this procedure is considered to be preferred if possible. However, the criteria of cases without femoral shortening osteotomy are not clear. In this study, we retrospectively analysed the clinical outcomes of patients performed THAs for high hip dislocation, and clarified the adaptation of THA with or without femoral shortening osteotomy. Methods. We included a total of 65 hip joints from 57 patients who underwent primary THA using Modulus stem for high hip dislocation from November 2007 to December 2015 at our institution. The mean follow up period was 5.2 years (2 – 10 years). The mean age at surgery was 65.4 years (Table 1). Thirty seven hips were classified as Crowe III, and twenty eight hips as Crowe IV based on Crowe classification. We classified patients into two groups based on the use of femoral osteotomy. Then, we compared the surgical time, blood loss, Japanese Orthopaedic Association (JOA) Score as clinical outcomes, preoperative position of the greater trochanter, the cup position, and complications between two groups. The position of the greater trochanter was measured the height of the tip of greater trochanter from the inter teardrop line. The cup center position was assessed by measuring the distance between the cup center and ipsilateral tear drop. Receiver operating characteristic (ROC) curves were plotted for deciding the cut-off value for the height of the greater trochanter. The cut-off value presented the maximum sensitivity and specificity was determined. Results and Discussion. Fifty three THAs were operated without femoral shortening osteotomy, and twelve THAs were performed with femoral shortening osteotomy. The surgical time was significantly longer in the osteotomy group than the non-osteotomy group. The mean height of the tip of the greater trochanter were 53.2±11.4mm in the non-osteotomy group and 92.2±19.7 mm in the osteotomy group (Table 2). The cut-off value of the height of greater trochanter evaluated from the ROC curve analysis was 69.5mm (Fig.1). There were no significant differences in clinical score between two groups. More ratio of revisions and fractures were observed in the osteotomy group with significant differences. Conclusion. There were significant differences in postoperative complications in osteotomy group compare to non-osteotomy group. In cases with a greater trochanter tip height of 69.5 mm or less, it may be considered to avoid femoral shortening osteotomy

Purpose. Crowe IV complete dislocated hips were thought to be difficult for primary THA. Correction for leg length discrepancy associated with nerve palsy or tough to reduction during surgery. Purpose of this study was to evaluate 3.5cm total leg length correction for any type of Crowe IV patients setting in anatomical positioning of acetabular cup with femoral shortening osteotomy. Materials & Methods. 24 hips were evaluated averaged 28 months after primary THA. Correction length of center of rotation, amount of femoral shortening, Harris hip score, and abductor muscle power recovery with MicroFet 2 caluculator. Bilateral cases were preformed with 6 months interval. Length of femur and tibia compared to contralateral normal side were evaluated from plain radiograms. Results. Average LLD before surgery was 7.3 (5 to 8.5) cm, but recovered within 3.5 cm (0.8 to 2.9) after surgery. One cm longer of femur in 9 patients, one cm longer of tibia in 12 patients, and 1cm longer both of femur and tibia in 5 patients compared to contralateral side before surgery. Average OR time was 92 minutes. All patients were women averaged age was 60 (34 to 75). Harris hip score improved from 45 to 92 before and latest follow-up. All patients did not need t-cane 2 years after surgery. Center of rotation was averaged 6.8 (5.2 to 8.1) cm reducted to anatomical position. Femoral shortening averaged 3.3 (1.7 to 4.5) cm, so total correction was 3.5cm (3.1–4.2). No nerve palsy and had good muscle recovery without T-cane. Patients with normal contra lateral side had averaged 2 cm (1.5∼3) heel up orthosis after surgery, but had no complaint about heel up situation in activity of daily living. Discussion & Conclusion. Amount of correction with leg length discrepancy during THA had controvertial issues especially in cases of completed dislocated hip joint. Several authors demonstrated that muscle-evoked potentials elicited by brain electric stimulation monitoring, but problems was occurred during epidural or spinal anesthesia. Averaged 3.5cm Total correction of leg length was very safe and satisfactory results for all Crowe IV patients

Introduction. The project of a modular, double-conicity stem is born from the need to obtain primary stability and correct osseointegration in patients with developmental hip dysplasia, or proximal femoral dysmorphisms requiring a femoral shortening osteotomy or presenting characteristics of non-adaptability to single-conicity or straight stems. Such an implant could also be employed in femoral nail failures, or lateral femoral neck fractures requiring prosthetic substitution. Aim of the study. To assess implantability of the new double-conicity stem in cadaver femurs, determining “fit and fill” and the behaviour of femoral cortical bone by means of Rx, CT and pre- and post-implantation mechanical testing. Methods. Seven double-conicity stems with anti-rotation fins were implanted in cadaver femurs of various sizes. All femurs underwent pre- and post-implantation radiological assessment for evaluation of fit and fill at the 2 levels corresponding to the 2 conicities, fins penetration, possible microfractures and stem positioning. Prior to implantation, templating was carried out to define the correct size of the stem to be implanted. Modular necks with cervico-diaphyseal angle of 125° or 135° (short or long) were implanted, to preserve the correct rotation center and femoral offset. In 2 femurs, mechanical testing was performed before and after implantation, in order to assess, by means of strain gauges, the variation of the tensional state of cortical bone under dynamic loading (gait cycle simulation). In 2 femurs, 3 cm chevron shortening osteotomies were performed and stabilized with the stem alone. Results. Implanted stems respected pre-operative planning. In the 2 cases in which shortening osteotomies were performed, the stem allowed for good meta-diaphyseal stability without the employment of fixation devices. Radiographic assessment evidenced a valid “fit and fill”. In 4 cases the stem was correctly aligned; in 2 cases it was positioned in 1° varus and in 1 case in 1° valgus. In the 2 osteotomy cases, penetration of the fins was good at the proximal level and slight distally. In the remaining 4 cases penetration at both levels ranged from slight to good. No microfractures, either intraoperative or following stress testing, were evidenced. Mechanical tests showed that stem implantation reduced deformation of the femoral cortical bone undergoing cyclic loading, in comparison with the pre-implantation situation. Conclusions. The double-conicity prosthetic stem showed good implantability, with the capacity to allow for stability in case of femoral shortening osteotomies without the use of plates or cerclage fixation. Mechanical testing also showed a correct load distribution, and a reduction of stress on femoral cortical bone in comparison with the state before implantation. Prospective clinical studies are necessary to assess efficacy and dependability from a clinical and radiographic viewpoint

Background. There are many difficulties during performing total hip replacement in high riding DDH. These difficulties include:. In Acetabular part: bony defect in antero lateral acetabular wall/finding true centre of rotation/shallowness of true acetabulum/hypertrophied and thick capsular obstacle between true and false acetabulum. In Femoral part: small diameter femoral shaft/excessive ante version/posterior placement of greater trochanter. anatomic changes in soft tissue & neurovascular around the hip including: adductor muscle contracture/shortening of abductor muscles/risk of sciatic nerve injury following lengthening of the limb after reduction in true acetabulum/vascular injury. The purpose of this lecture is how to manage above problems with using reinforcement ring (ARR) for reconstruction of true acetabulum and step cut L fashion proximal femoral neck shortening osteotomy in a single stage operation. Method. 23 surgeries in 19 patients, including 18 female and one male were performed by me from Jan. 1997 till Dec. 2009. Six patients had bilateral hip dislocation, but till now only four of them had bilateral stepped operation. Left hip was involved in 15 cases (65.2%). The average age was 40 years old. All hips were high riding DDH according to both hartofillokides and crowe classification. Reconstruction of true acetabulum was performed with aid of reinforcement ring and bone graft from femoral head in all cases. Trochantric osteotomy was done in all, followed by fixation with wire in 22 cases which needed two revisions due to symptomatic non union (9%). Hooked plate was use in one case for trochantric fixation. Due to high riding femur, it was necessary to performed femoral shortening in neck area as a step cut L fashion. In two patient, one with bilateral involvement, after excessive limb lengthening following trial reduction, it was necessary to performed concomitant supracondylar femoral shortening. (3 cases = 13%). 22 mm cup & miniature muller DDH stem were used in 18 cases (78.26%). In 5 cases, one bilaterally, non cemented stem and 28 mm cemented cup in ring were used. Primary adductor tenotomy was performed in 9 cases. Secondary adductor tenotomy needed in 2 cases (totally = 47.82%). Repair of iatrogenic femoral artery tear after traction injury with retractor, occurred in 2 cases (8.69%). All patients evaluate retrospectively. Average follow up month is 68.7. Results. One case of left acetabular component revision due to painful bony absorption in infero medial part of ring with poor inclination wad done, after 2 years of primary operation. Know after 13 years she has had early signs of stem loosening in the same side. Another acetabular component revision following traumatic dislodgment of cup and cement from ring was performed after 13 months from primary operation. Again she had poor implant inclination. So revision rate is 8.69%. (One case will need revision in near future, so the revision rate will increase to 13%) Radiological wires breakage which were used for greater trochanteric fixation, could be seen in 11 cases (47.82%), but only two of them with functional impairment needed to re-fixation with Menen plate(18.18% of trochanteric non union). Average limb lengthening after operation is 4.3 Cm (2-7 Cm). Only one case of transient Sciatic nerve paresis had happened for 2 months followed by complete recovery. Two case of secondary adductor tenotomy wre done, one after traumatic dislocation of prosthesis with pubic fracture, and the other one after restriction of hip abduction. The average Harris hip score from 23 pre -operatively has been increase to 85.38. (The pre op. scores were 12.625 – 40.775/The post op. scores were 64.92 – 96). No post operative infection was seen. Discussion. This is a midterm follow up survey, but 7 cases have more than 9 years follow up with only one stem loosening (11% long term loosening rate). It is a challenging procedure for performing joint replacement in high riding DDH, if so using reinforcement ring with graft for true acetabulum reconstruction and getting primary proximal femoral shortening in a step cut L fashion around the lesser trochanteric region would be a worthy procedure. In high riding DDH due to hypoplasia of lesser trochanter, there is not a significant difference in bone resistance and it is possible to get shortening in this area without fearing of deco promising bony stability. The average shortening is 3 Cm. In specific cases with more severe contracture for preventing neuro-vascular complication, concomitant shortening osteotomy in supracondylar area is recommended. Although greater trochanter fibrous union has produced less functional impairment, but a better technique should be considered. Distal and lateral advancement of osteotomised greater trochanter lead to better abductor muscle performance and less limp. Adductor tenotmy has a great importance in contracted soft tissue, so in any case with abduction limitation it should be performed

Background. Subtrochanteric femoral shortening and corrective osteotomy are considered to be an integral part of total hip arthroplasty for a completely dislocated hip or severe deformity of the proximal femur. A number of alternative femoral osteotomy techniques, transverse, oblique, step-cut, and V-shaped, have been described. Becker and Gustilo reported the “double-chevron subtrochanteric shortening derotational femoral osteotomy,” which is reasonable in that the osteotomy site is torsionally more stable and can be stabilized with a shorter stem. We have simplified this procedure, and performed it without a trochanteric osteotomy. We describe a simplified double-chevron osteotomy and provide the clinical results from a series of 22 successful procedures. Methods. In this series, we performed 22 cementless total hip arthroplasties combined with double-chevron subtrochanteric osteotomies between 1997 and 2002. There were 17 females and 2 males. Their average age at the time of the operation was 59 years old (range, 41–74 years old). Thirteen of these hips were congenitally dislocated hips (Crowe IV), and 8 hips were after proximal femoral osteotomies using a procedure described by Schanz or valgus osteotomy, and 1 hip was an ankylosed hip in malposition. Results. The mean length of the operation was 128 minutes (range, 80–215 minutes). The mean total blood loss was 1442 g (range, 809–2007 g), which included both the intraoperative blood loss and postoperative blood loss. After an average of 7.6 years of follow-up, the Japanese Orthopaedic Association Hip Score improved from 48 to 79. The mean amount of intraoperative femoral resection was 29 mm (range, 10–45 mm). The postoperative highest point of the greater trochanter was lowered by a mean of 50 mm (range, 6–74 mm) compared with its preoperative point on the radiograph. The calculated measurement (lowered greater trochanter minus intraoperative femoral resection) of leg lengthening was a mean 21 mm (range, −4–51 mm). Two acetabular component migrated, and one case required revision surgery. The other components showed no evidence of migration or loosening. There were radiolucent lines of less than 2 mm thickness in zones 1, 2, and 3 in one acetabular as previously mentioned revision case. One femoral component had subsidence 3 mm. Four femoral components had radiolucencies. One osteotomy site failed union and was varus deformity. After 6 years after the operation, the case required revision using cementless long stem. All femoral components achieved fixation with an optimal interface at the latest follow-up. Three types of complications were observed. There were no cases of neurologic abnormality, infection. There were 4 early dislocations, 3 proximal splits, and 1 nonunion at the osteotomy site. All femoral fragment fractures during the operation and all dislocations after the operation were in the Crowe IV group. Conclusions. Our study shows that double-chevron subtrochanteric osteotomy provided acceptable results for subtrochanteric femoral shortening and corrective osteotomy. The operation procedure is simple and the operation time is much shorter. However, THA combined with subtrochanteric osteotomy is a technically demanding treatment option

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Introduction. Limb length discrepancy (LLD) is one of the major reasons of dissatisfaction after total hip arthroplasty(THR) and limb equalization after THR in unilateral developmental dysplasia of the hip (DDH) is very important. study designed to measure the difference of adult femoral length between normal and dislocated hip in unilateral DDH. Method. Sixty patients with unilateral high riding DDH (crow type 3,4) who were underwent THR included. All the cases had digital lower limb scanograms. Exclusion criteria was any previous hip or femur surgery, any rheumatoid disease, history of any disease that affect the growth. All the scanograms measured by one fellowship of adult reconstruction and one radiologist specialized in musculoskeletal imaging. Each one repeated the measurements two months later blindly and inter observer and intra observer reliability checked. Each one measured femoral length in both sides from greater trochanter(GT), to the distal surface of the femoral condyles. Results. 59 female and one males included. Average age was 27.5 years (19–50 years). Inter observer reliability index were excellent (ICC 98%). Only 6 cases (10%) had exactly equal femoral length, 31(52%) cases were longer on the dislocated side and 23 (38%) cases were shorter. Average overgrowth was 6.1 mm (Range: 1–22) and average undergrowth was 10.7 (Range 1–21). 35 cases (58.3%) cases had 5 mm or more differences and 30% had 5–10 mm .17 cases (28.3%) had at least 10 mm difference that 8 cases (13%) had shorter and 9 cases (15%) had longer femur on dislocated side. Maximum difference was 22 mm over length on dislocated side. Conclusions. More than half of patients with unilateral high riding DDH have longer femur on the dislocated side and 15% of them are longer than 10 mm. we recommend to get the scanograms in all the unilateral DDH cases to avoid post-operative limb discrepancy and detecting the amount of shortening in cases that need femoral shortening

Introduction. Bulk bone grafting of the cup is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it carries a risk of the graft collapse in the mid-term or long-term results. The purpose of this study is to describe our new bulk bone grafting technique and review the radiographic and clinical results. Patients and Methods. We retrospectively reviewed 85 hips in 74 patients who had undergone bulk bone grafting in total hip arthroplasty for developmental dysplasia between 2008 and 2013. We excluded patients who had any previous surgeries or performed THA with the femoral shortening osteotomy. According to the Crowe classification, 4 hips were classified as Type 1, 28 as Type 2, 35 as Type 3, and 18 as Type 4. Follow-up was at a mean of 4.0 years (1 to 6.1). The surgery was performed using the direct anterior approach on a standard surgical table. The acetabulum was reamed for as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After the pressfit fixation of the cup was achieved, two or three screws were used to reinforce the fixation. The superior defect of the acetabulum was packed with sufficient amount of morselized bone graft. Then, the bulk bone was placed on the morselized bone graft and fixed with one screw. Post-operatively, there were no restrictions to movement or position. On the first day after surgery, the patient was allowed to walk with full weight-bearing. We measured the height of the hip center from the interteardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15% of the pelvic height. Results. The mean height of the hip center was 10.2 (4.1∼18.0)% of the pelvic height and the 81 (95.2%) cups were placed within the anatomical hip center. We observed no collapsed grafts, no severe absorption of the grafts, and no migration of the cup at the last follow-up. Conclusion. In our technique, there is no concern of the bulk bone graft collapse even in the long-term results, because the cup is not supported by the bulk bone graft but by the host bone with the pressfit and additional screws. Moreover, 95.2% of all cups were placed within the anatomical hip center. In conclusion, our new bulk bone graft technique would be simple to perform and an excellent option for the reconstruction of the acetabulum in patients with severe dysplasia

Aim. To review the patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication. Methods. A retrospective review of all patients who have undergone the procedure, looking at the pre-operative deformity, correction achieved, time to union and complications. Results. Seven patients underwent correction under the senior author from 2003 to today. Average age was 46 years (range 32–60 years). All had femoral shortening, average 2.7cm (range 2–4cm). Each also had at least one other plane of deformity with rotation being the next most commonly encountered in 5 out of the 7 (average 33 degrees). 2 had tri-planar deformity with the 5 having bi-planar deformity. Average time to union was 18.4 months (range 7 to 39 months) with an average of 1.6 operations (range 1 to 3 operations) to union. Two patients are awaiting union, 1 has required repeat plating and one is a primary fixation and correction awaiting union. Conclusion. Correction of multiplanar deformity of the femur is challenging. Osteotomy with decortication provides a technique to achieve correction of significant femoral deformity union achieving full multi-planar deformity correction in a single operation. This paper provides guidance and a technical description of the operative technique

We reviewed patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication by retrospective reviewing all patients who have undergone the procedure, looking at the pre-operative deformity, correction achieved, time to union and complications. Seven patients underwent correction under the senior author from 2003 to today. Average age was 46 years (range 32–60 years). All had femoral shortening, average 2.7cm (range 2–4 cm). Each also had at least one other plane of deformity with rotation being the next most commonly encountered in 5 out of the 7 (average 33 degrees). 2 had tri-planar deformity with the 5 having bi-planar deformity. Average time to union was 18.4 months (range 7 to 39 months) with an average of 1.6 operations (range 1 to 3 operations) to union. Two patients are awaiting union, 1 has required repeat plating and one is a primary fixation and correction awaiting union. Correction of multiplanar deformity of the femur is challenging. Osteotomy with decortication provides a technique to achieve correction of significant femoral deformity union achieving full multi-planar deformity correction in a single operation. This paper provides guidance and a technical description of the operative technique

This study aimed to characterise severe open femoral fractures sustained by military personnel and to describe their orthopaedic management and preliminary outcomes. The UK Military Trauma Registry was searched for open femoral fractures sustained between 2006–2010. Clinical records and radiographs were reviewed and data gathered on demographics, injury, management and preliminary outcomes. Thirty-four patients with 34 open femoral fractures were eligible for inclusion. The mean NISS was 22.4 (SD 12.28). Nineteen fractures were caused by gunshot wounds (56%), with the remainder due to blasts. Three patients (9%) suffered Grade 4 segmental bone loss. Intramedullary nailing was used in 22 patients (69%). A minimum of 12 month follow up was available for 33 patients (97%). Twenty-three patients (70%) had achieved fracture union within the first twelve months. One patient suffered deep infection requiring surgical debridement. Ten patients (30%) underwent a revision procedure due to femoral shortening or malunion: two required a transfemoral amputation. There was a significant association between bone loss and a poor outcome (revision surgery) at 12 months (p=0.00016). Infection rates were significantly lower in open femoral fractures when compared to similar published work on open tibial fractures (p=0.0257)

Introduction. Total hip arthroplasty (THA) for a highly dislocated hip can be problematic and technically challenging. Our previous study on cemented THA with subtrochanteric femoral shortening osteotomy revealed a high incidence (20%) of non-union. Therefore, in 2008, we introduced reverse hybrid THA using S-ROM stem for the treatment of a highly dislocated hip. The purpose of this study was to assess the short-term clinical outcomes of this new method. Patients and methods. Between 2008 and 2014, 13 consecutive reverse hybrid THAs were performed on nine female patients with highly dislocated hips. The average age at the time of operation was 66 years (range, 55–85 years). The acetabular component was fixed in the true acetabulum with bone cement. Transverse osteotomy was performed below the lesser trochanter to shorten the femur and to prevent over-lengthening. The proximal sleeve of the S-ROM stem was then fixed within the proximal fragment, and the distal fin provided rotational stability of the distal fragment. Thus, the two fragments were fixed to each other with the S-ROM stem, and the resected segment was longitudinally cut for grafting at the junction. The postoperative follow-up period was an average of 4 years (range, 1–7 years), and no patients were lost. Preoperative and final Japanese Orthopaedic Association (JOA) hip score, operation time, bleeding amount, intraoperative and postoperative complications, bone healing at the osteotomy site, implant loosening, and revision surgery were retrospectively investigated. Results. The mean JOA hip score improved from 56 points preoperatively to 82 points postoperatively. The operation time and amount of bleeding were an average of 208 min and 643 g, respectively. The mean length of femoral resection was 4 cm (range, 2–6 cm), and the tip of the greater trochanter migrated an average distance of 7 cm (range, 5–9 cm) distally. The calculated limb lengthening was an average of 3 cm (range, 2–4 cm). Intraoperative fracture was seen in two patients, but no repeat operation was required. Two patients experienced postoperative dislocation in their hips, but additional surgery was not necessary. Postoperative nerve palsy did not occur in any patient, and all the osteotomy sites showed complete bone union. There was no implant loosening seen in any patient, and there was also no need for revision surgery. Discussion and conclusions. To achieve satisfactory outcomes with this method, resection of necessary and sufficient length of femur and accomplishment of adequate fixation between the proximal and distal fragments are necessary. In this study, dislocation occurred in two patients, and no nerve palsy was seen. Larger femoral heads may be recommended to eradicate dislocations. In cases where metaphysis of the femur is hypoplastic or the medullary canal is wide, reaming and stem insertion should be carefully performed. In this series, no additional surgery was required for the intra- and post-operative complications, and the osteotomy sites achieved bone union in all patients. Therefore, we recommend the use of this method, although longer follow-up periods are necessary

Introduction. Bulk bone grafting is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it is a technically demanding surgery with several critical issues, including graft resorption, graft collapse, and cup loosening. The purpose of this study is to describe our new bone grafting technique and review the radiographic and clinical results. Patients and Methods. We retrospectively reviewed 105 hips in 89 patients who had undergone covered bone grafting (CBG) in total hip arthroplasty for developmental dysplasia. We excluded patients who had any previous surgeries or underwent THA with a femoral shortening osteotomy. According to the Crowe classification, 6 hips were classified as group I, 39 as group II, 40 as group III, and 20 as group IV. Follow-up was at a mean of 4.1 (1 ∼ 6.9) years. The surgery was performed using the direct anterior approach. The acetabulum was reamed as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After pressfit fixation of the cup was achieved, several screws were used to reinforce the fixation. Indicating factor for using CBG was a large defect where the acetabular roof angle was more than 45 degrees and the uncovered cup was more than 2 cm (Fig.1). The superior defect of the acetabulum was packed with a sufficient amount of morselized bone using bone dust from the acetabular reamers. Then, the grafted morselized bone was covered with a bone plate from the femoral head. The bone plate was fixed with one screw to compact the morselized bone graft. The patient was allowed to walk bearing full weight immediately after surgery. We measured the height of the hip center from the teardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15 % of the pelvic height, which was nearly equal to 30 mm, because the mean pelvic height was 210 mm. Results. The mean height of the hip center was 9.8 (4.1∼18.0) % of the pelvic height and the 101 (96.2%) cups were placed within the anatomical hip center. Radiographically, in all patients, the host-graft interface became distinct and the new cortical bone in the lateral part of the plate bone appeared within 1 year after surgery (Fig.2, 3). We observed no absorption of the plate bone graft and no migration of the cup at the last follow-up. Conclusion. CBG technique is simple, because the bone graft is always performed after the pressfit of the cup is achieved. Moreover, patients require no partial weight bearing postoperatively, because the cup is supported by the host bone with the pressfit and additional screws. The CBG technique would be an excellent option for the reconstruction of the acetabulum in patients with severe dysplasia to avoid a high hip center and bulky bone grafting

Background. Sciatic nerve palsy is a relatively rare, but one of the serious complications after total hip arthroplasty (THA). The prevalence of nerve palsy after THA has been reported to range from 0.3% to 3.7%. Previous authors have speculated that causes could include overlengthening, compression from a hematoma, from extruded metylmethacrylate, or from retractor placement, or laceration from a screw used in the acetabular component. Leg lengthening more than 4 cm was associated with sciatic nerve palsy in the past literature. But there is no report about maximum safety leg lengthening to prevent sciatic nerve palsy significantly. The purpose of this study was to identify the safety rage of leg lengthening to prevent sciatic nerve palsy in THA for the patients with adult hip dislocation. Methods. Forty two consecutive patients47 jointswith Crowe type â?¢ or â?£ were performed THA. Nine joints were Crowe type â?¢ and thirty eight joints were type â?£ in this study. All patients were female. The average age at the time of surgery was 63.3 years (range, 40–77 years). The average patient body weight was 50.5 kg and the average height was 150 cm (body mass index: 22.3 kg/m. 2). The average follow-up was 9.9 years (range, 1–21). See Table1 The socket was placed at the level of the original acetabulum, and femoral shortening osteotomy was performed in 27 joints. Leg lengthening (LL) was defined the vertical distance from the tip of greater trochanter to the tear drop line. The mean LL was 3.1 cm (range, 1.5–6.7 cm). Clinical Harris hip score and sciatic nerve palsy was retrospectively assessed from the patients records. The correlation between LL, the percent LL (cm) divided by body height (cm) (%LL/BH) and the incidence of sciatic nerve palsy was investigated. Results. There were two sciatic nerve palsy (4.3%). These leg lengthening were 5.2 cm and 6.7 cm, respectively. These patients had complete recovery of neurological function. A significant correlation between the amount of LL and the incidence of sciatic nerve palsy was identified. LL more than 5 cm and %LL/BH â?§ 3.6 were significant risk factors of sciatic nerve palsy (p=0.0194, p=0.0028). See table2.3 Body mass index, preoperative hip flexion, previous operations were not associated with sciatic nerve palsy. Harris hip scores improved from a mean of 57.6 points prior to surgery to an average of 83.1 points at the latest follow-up. Kaplan- Meier survivorship analysis at 5 and 10 years revealed a cumulative survival rate of 94.1% and 64.2% respectively, with any implant revision as the end point. There were six cases of dislocations, which were successfully treated conservatively. Infection was not observed. Conclusions. Leg lengthening more than 5 cm and %LL/BH â?§ 3.6 were significant risk factors of sciatic nerve palsy

Introduction and Aims. The 21. st. Century has seen ceramic bearings become an increasingly popular choice in total hip arthroplasty due to their high wear resistance and inert wear debris without osteolysis promising a long term bearing solution. Early ceramic bearings were hindered by fracture but improved manufacturing processes and materials subsequently produced stronger ceramics. These third generation ceramics showed greatly reduced fracture rates but there is limited evidence in the literature reporting their long term survival and wear characteristics. The purpose of this study was to determine osteolysis and survival rates of Alumina ceramic bearings in cementless total hip arthroplasties with a minimum follow-up of 15 years. Methods. We analyzed a series of 301 third-generation alumina-on-alumina cementless primary total hip replacements in 283 patients. The average age of the patients at the time of the arthroplasty was fifty-eight years, 51% were in women and 54% were right sided. All procedures were performed using the same surgical technique and the same implant at a single centre. Patients were followed up at six weeks, one, two, five, ten and 15 years. At 15 years postoperatively 46 patients (17%) had died of unrelated causes and 31 (10.2%) were lost to follow-up. Patients were assessed clinically and radiographically. Retrieved bearings were analyzed for wear. Results. At the time of the latest follow-up the mean Harris Hip Score was 94 points and 97% of the patients scored an excellent or good result with less than 4% having moderate residual pain. Radiographically, all patients assessed had evidence of stable bony ingrowth. Minor osteolysis was seen adjacent to 4% of cups and in none of the stems. There were eleven revisions in all, four stem revisions due to periprosthetic fracture, one secondary to aseptic loosening and one to facilitate a femoral shortening osteotomy. One cup was revised for aseptic loosening and one cup was revised for soft tissue impingement. One cup underwent revision due to acetabular osteolysis due to metallosis with some ceramic wear caused by neck impingement. There were two revisions for ceramic fracture, one liner and one femoral head. Overall, the survival rate of the implants for any cause revision was 96% at 15 years, with. The rate of survival of both components, with revision because of aseptic loosening or osteolysis as the end point, was 99% at 15 years. Analysis of retrieved femoral heads identified a median wear rate of 0.2mm3/year. Conclusion. Ceramic bearings were designed to overcome the problem of osteolysis due to wear from polyethylene bearings. This study has shown that Alumina bearings in cementless primary total hip arthroplasty have an excellent survival rate at 15 years with good function, low wear rate and no adverse radiographic changes typical of osteolysis. The fracture rate was low in our study. These findings strongly supporting the use of Ceramic as a bearing choice for the 21. st. Century

Introduction. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur. Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required. Purpose of the study is to verify surgical procedures and explore reconstruction options on severe hip dysplasia. Materials and methods. In last 25 years, 2308 arthroplasties were performed in dysplastic hips (565 cases had a previous femoral osteotomy). In 128 cases was required a correction of femoral side deformity: in 64 cases was performed a greater trochanter osteotomy (in 12 of these a proximal femoral shortening was associated), 55 cases were treated by a shortening subtrochanteric osteotomy (that allows corrections in any plane) and in 9 cases was performed a distal femur osteotomy. Discussion. Long-term results in these patients are steadily inferior to those obtained in general population (70% survival rate at 15 years). On femoral side early failures reflect learning curve and are due to insufficient fixation of osteotomies. Despite this, the more promising outcomes are concerning shortening sub-trochanteric osteotomy with uncemented stem but only early and mid-term data are available

Introduction. Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique. Aim. The aim of the study was to review consecutive patients who underwent closed femoral rotational or shortening osteotomy using an intramedullary saw over a ten-year period. Material & Methods. Forty femoral rotational and/or shortening osteotomies using an intramedullary saw were performed on thirty-six patients, between January 2001 and June 2011. The main indications were post-traumatic leg length discrepancies and congenital rotational abnormalities. Clinical & radiological follow up mean was 16.3 months. Results. Twenty one osteotomies were performed for femoral shortening with the mean correction of 3.5 cm. Nineteen osteotomies were performed for correction of torsion; there was a mean correction of 28.64 degrees with Internal rotation and 35 degrees with external rotation osteotomies. Fourteen patients required removal of locking screws. There were two patients with heterotrophic ossification, two patients with wound infection (one deep infection). One patient had a materiovigilance incidence and one patient had vascular complication requiring embolisation. The subjective results showed 37 osteotomies were satisfied with their operation, functional recovery and aesthetic appearance of the scars. Conclusion. Closed osteotomy of femur for correction of LLD and torsion using an intramedullary saw represents a reliable and effective procedure. Despite the complications, the original goal of the surgery was achieved in 37 of the 40 limbs treated. Patient satisfaction was achieved in 92.5 % of 40 osteotomies