Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Introduction. Leg length discrepancy (LLD) is a common sequalae of limb reconstruction procedures. The subsequent biomechanical compensation can be directly linked to degenerative arthritis, lower back pain, scoliosis and functional impairment. It becomes particularly problematic when >2cm, established as a clinical standard. This two-arm experimental study assesses how reliable an iPhone application is in the measurement of LLD at different distances in control and LLD patients. Materials and Methods. 42 participants were included in the study, divided evenly into 21 control and 21 LLD patients. A standardised measurement technique was used to obtain TMM and iPhone application measurements, taken at a distance of 0.25m, 0.50m and 0.75m. Results. The mean discrepancy of iPhone-based measurements in the control group was 1.57cm, 1.59cm and 2.19cm at 0.25m, 0.50m and 0.75m respectively. This compares to measurements in the LLD cohort with a mean discrepancy of 1.71cm, 1.85cm and 2.19cm. The overall mean discrepancy of iPhone data was 1.78cm in the control cohort compared to 1.92cm in the LLD cohort. Conclusions. Results suggest that the iPhone application can be used to identify clinically significant leg length discrepancies. At 0.75 metres anomalous results become more prevalent and the accuracy of the application appears to decline. The results also suggest the application is slightly more accurate in the control group, nevertheless, in distances up to 0.50 metres the mean discrepancy sits within the 2cm standard of clinically significant LLD

Abstract. Congenital posteromedial bowing of tibia (CPMBT) progresses with decreasing deformity and increasing shortening. Lengthening in CPMBT has not been studied extensively. Our series compares duration and complications of lengthening in younger vs older children. Methods. 28 tibial lengthenings (23 patients) by a single surgeon, divided into two equal groups of 14 segments: group-A ≤ 5 years, Group-B > 5 years. Lengthening was done in all with external fixators. We measured preoperative (bo) and postoperative (po) deformities, initial limb length discrepancy (LLD), LLD at maturity (LLDm), % LLD, amount of lengthening (AmtL) and %L, external fixator duration (EFD) and external fixator index (EFI). We graded complications by Lascombes' criteria, results by ASAMI Bone score. Results. Mean age was 8.8 ± 7.1 years. Follow-up was 7.9 years. Group-A had significantly greater preoperative deformities. LLD was similar in both. Expected LLD at maturity (LLDM) using the multiplier method was greater than previously reported (group-A: 4.4 – 9.5 cm; group-B: 2.5 – 9.7 cm).%L was 24% in group-A and 15.7% in group-B (p=0.002). EFD and EFI were lesser in group-A than group-B. Lascombes' triple contract was fulfilled in 11/14 lengthenings in group-A vs. 3/14 in group-B. ASAMI bone score was good and excellent in both groups. Conclusions. In our large series of CPMBT lenghtenings, we found younger children presenting with large deformities and LLDm could be safely lengthened with lesser EFD and complications than older children

Introduction. Legg-Calvé-Perthes disease (LCPD) often results in femoral head deformity and leg length discrepancy (LLD). Objective of this study was to analyse femoral morphology in LCPD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalisation on proximal and subtrochanteric femoral lengths. Materials and Methods. All patients treated for LCPD in our institution between January 2013 and June 2020 were retrospectively reviewed. Patients with unilateral LCPD, LLD of ≥5mm and long leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD) and subtrochanteric femoral length were compared between LCPD side and unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. Results. 79 patients were included, 21/79 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort the average LLD was 1.8cm (95% CI 1.5 – 2.0), average ATD difference was 1.8cm (95% CI −2.1 – −1.9) and average subtrochanteric difference was −0.2cm (95% CI −0.4 – 0.1). In the epiphysiodesis group the average LLD before epiphysiodesis was 2.7 (1.3 – 3.4) cm and 1.3 (−0.5 – 3.8) cm at skeletal maturity. In the non-epiphysiodesis group the average LLD was 2.0 (0.5 – 5.1), p=0.016. The subtrochanteric region on the LCPD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the non-epiphysiodesis group: −1.0 (−2.4 – 0.6) versus 0.1 (−1.0 – 2.1), p<0.001. Conclusions. This study concludes that LLD after LCPD originates from the proximal segment only. In patients who had had a contralateral epiphysiodesis, the subtrochanteric femoral region was significantly longer on the LCPD side. These anatomical changes need to be considered by paediatric surgeons when advising leg length equalisation procedures, and by arthroplasty surgeons when LCPD patients present for hip arthroplasty

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

Introduction. Congenital posteromedial bowing of tibia (CPMBT) is characterized by a decreasing deformity and an increasing limb shortening. Our series compares the duration and complications of lengthening in younger vs older children. Materials and Methods. We studied 28 tibial lengthenings in 23 patients, divided into two equal groups of 14 segments: group-A ≤5 years (preschool) and Group-B >5 years. We measured preoperative (bo) and postoperative (po) sagittal, coronal, and oblique plane deformities, limb length discrepancy (LLD), amount of lengthening (AmtL), percentage lengthening (%L), external fixator duration (EFD) and external fixator index (EFI). Complications were graded by Lascombes’ criteria, results by ASAMI Bone score. Results. Mean age= 8.8 ± 7.1 years; mean follow-up= 7.9 years. Group-A had significantly greater bo-sagittal, coronal, and oblique plane deformities. LLD (3.4 cm in group-A vs. 4.1 cm in group-B) was similar in both. LLD at maturity (LLD. M. ) by multiplier method ranged 4.4–9.5 cm in group-A and 2.5–9.7 cm in group-B. Though AmtL (3.5 cm and 4.1 cm) was similar in both, %L was 24% in group-A and 15.7% in group-B (p=0.002). EFD (116.6 days) and EFI (33.7 days/cm) were lesser in group-A vs group-B (200.3 days, p=0.001; 50.2 days/cm, p=0.01). Lascombes’ criteria were fulfilled in 11/14 lengthenings in group-A vs. 3/14 in group-B. ASAMI bone score was good and excellent in both groups (p=0.44). Conclusions. Younger children with large deformities and LLD. M. could be safely lengthened with lesser external fixator duration and complications than in older children

Summary. The mathematical model has proven to be highly accurate in measuring leg length before and after surgery to determine how leg length effects hip joint mechanics. Introduction. Leg length discrepancy (LLD) has been proven to be one of the most concerning problems associated with total hip arthroplasty (THA). Long-term follow-up studies have documented the presence of LLD having direct correlation with patient dissatisfaction, dislocation, back pain, and early complications. Several researchers sought to minimize limb length discrepancy based on pre-operative radiological templating or intra-operative measurements. While often being a common occurrence in clinical practice to compensate for LLD intra-operatively, the center of rotation of the hip joint has often changes unintentionally due to excessive reaming. Therefore, the clinical importance of LLD is still difficult to solve and remains a concern for clinicians. Objective. The objective of this study is two-fold: (1) use a validated forward-solution hip model to theoretically analyze the effects of LLD, gaining better understanding of mechanisms leading to early complication of THA and poor patient satisfaction and (2) to investigate the effect of the altered center of rotation of the hip joint regardless LLD compensation. Methods. The theoretical mathematical model used in this study has been previously validated using fluoroscopic results from existing implant designs and telemetric devices. The model can be used to theoretically investigate various surgical alignments, approaches, and procedures. In this study, we analyzed LLD and the effects of the altered center of rotation regardless of LLD compensation surgeons made. The simulations were conducted in both swing and stance phase of gait. Results. During swing phase, leg shortening lead to loosening of the hip capsular ligaments and subsequently, variable kinematic patterns. The momentum of the lower leg increased to levels where the ligaments could not properly constrain the hip leading to the femoral head sliding from within the acetabular cup (Figure 1). This piston motion led to decreased contact area and increased contact stress within the cup. Leg lengthening did not yield femoral head sliding but increased joint tension and contact stress. A tight hip may be an influential factor leading to back pain and poor patient satisfaction. During stance phase, leg shortening caused femoral head sliding leading to decreased contact area and an increase in contact stress. Leg lengthening caused an increase in capsular ligaments tension leading to higher stress in the hip joint (Figure 2). Interestingly, when the acetabular cup was superiorized and the surgeon compensated for LLD, thus matching the pre-operative leg length by increasing the neck length of the femoral implant, the contact forces and stresses were marginally increased at heel strike (Figure 3). Conclusion and Discussion. Altering the leg length during surgery can lead to higher contact forces and contact stresses due to tightening the hip joint or increasing likelihood of hip joint separation. Leg shortening often lead to higher stress within the joint. Further assessment must be conducted to develop tools that surgeons can use to ensure post-operative leg length is similar to the pre-operative condition. For any figures or tables, please contact authors directly

Introduction. Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails. Materials & Methods. A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications. Results. 21 nails (18 femoral, 2 tibial, 1 humeral) were inserted in 6 adult and 13 paediatric patients. Post-traumatic and congenital/developmental LLD were the most common indications for surgery in the adult and paediatric cohorts respectively. ORDER was employed in 11 cases (9 femurs and 2 tibias). Treatment goals were achieved in all but one case. Complications included superficial infection, locking bolt migration, periprosthetic fracture and component failure. Seven patients required unplanned returns to theatre. Conclusions. The Fitbone nail is an established option for intramedullary limb lengthening, however its use in the UK has been relatively limited compared to the PRECICE until 2021. Our data helps to define its place for limb lengthening and complex deformity correction in both adult and paediatric patients, including in humeral lengthening and retrograde femoral insertion across an open physis. We have identified important potential risks and novel techniques to simplify surgery and avoid complications

Introduction. Limb-length discrepancy (LLD) is a common postoperative complication after total hip arthroplasty (THA). This study focuses on the correlation between patients’ perception of LLD after THA and the anatomical and functional leg length, pelvic and knee alignments and foot height. Previous publications have explored this topic in patients without significant spinal pathology or previous spine or lower extremity surgery. The objective of this work is to verify if the results are the same in case of stiff or fused spine. Methods. 170 patients with stiff spine (less than 10° L1-S1 lordosis variation between standing and sitting) were evaluated minimum 1 year after unilateral primary THA implantation using EOS® images in standing position (46/170 had previous lumbar fusion). We excluded cases with previous lower limbs surgery or frontal and sagittal spinal imbalance. 3D measures were performed to evaluate femoral and tibial length, femoral offset, pelvic obliquity, hip-knee-ankle angle (HKA), knee flexion/hyperextension angle, tibial and femoral rotation. Axial pelvic rotation was measured as the angle between the line through the centers of the hips and the EOS x-ray beam source. The distance between middle of the tibial plafond and the ground was used to investigate the height of the foot. For data with normal distribution, paired Student's t-test and independent sample t-test were used for analysis. Univariate logistic regression was used to determine the correlation between the perception of limb length discrepancy and different variables. Multiple logistic regression was used to investigate the correlation between the patient perception of LLD and variables found significant in the univariate analysis. Significance level was set at 0.05. Results. Anatomical femoral length correlated with patients’ perception of LLD but other variables were significant (the height of the foot, sagittal and frontal knee alignment, pelvic obliquity and pelvic rotation more than 10°). Interestingly some factors induced an unexpected perception of LLD despite a non-significant femoral length discrepancy less than 1cm (pelvic rotation and obliquity, height of the foot). Conclusions. LLD is a multifactorial problem. This study showed that the anatomical femoral length as the factor that can be modified with THA technique or choice of prosthesis is not the only important factor. A comprehensive clinical and radiological evaluation is necessary preoperatively to investigate spinal stiffness, pelvic obliquity and rotation, sagittal and coronal knee alignment and foot deformity in these patients. Our study has limitations as we do not have preoperative EOS measurements for all patients. We cannot assess changes in leg length as a result of THA. We also did not investigate the degree of any foot deformities as flat foot deformity may potentially affect the patients perception of the leg length. Instead, we measured the distance between the medial malleolus and ground that can reflect the foot arch height. More cases must be included to evaluate the potential influence of pelvis anatomy and functional orientation (pelvic incidence, sacral slope and pelvic tilt) but this study points out that spinal stiffness significantly decreases the LLD tolerance previously reported in patients without degenerative stiffness or fusion

Introduction. Leg length discrepancy (LLD) in patients with unilateral developmental dysplasia of the hip (DDH) can be problematic for both patients and surgeons. Patients can acquire gait asymmetry, back pain, and arthritis. Surgical considerations include timing of correction and arthroplasty planning. This study audits standing long leg films performed at skeletal maturity in our patients. The aim of this study is to identify if surgical procedure or AVN type could predict the odds of needing an LLD Intervention (LLDI) and influence our surveillance. Materials and Methods. Hospital database was searched for all patients diagnosed with DDH. Inclusion criteria were patients with appropriately performed long leg films at skeletal maturity. Exclusion criteria were patients with non DDH pathology, skeletally immature and inadequate radiographs. All data was tabulated in excel and SPSS was used for analysis. Traumacad was used for measurements and AVN and radiologic outcome grades were independently classified in duplicate. Results. 110 patients were identified. The mean age of follow-up was 15 years with final average LLD of 1mm(±5mm). The DDH leg tended to be longer and length primarily in the femur. 31(28.2%) patients required an LLDI. 19 Patients had a final LLD >1.5cm. There was no statistical significant difference in the odds of needing an LLDI by type of surgical procedure or AVN. AVN type 4 was associated with greatest odds of intervention. The DDH leg was more likely to require ipsilateral epiphysiodesis or contralateral lengthening in Type 1 and 2 AVN. Conclusions. The DDH leg tends to be longer, leg lengths should be monitored, and leg length interventions are frequently required irrespective of previous DDH surgical procedure or the presence of AVN

Introduction. This is a report of the outcome of management of congenital pseudoarthrosis of the tibia (CPT) at skeletal maturity. Materials and Methods. Retrospective study. Inclusion criteria:. CPT Crawford IV. Skeletally maturity. Availability of radiographs and medical records. Outcome: union rate, healing time, residual deformities, ablation and refracture. Results. 23 patients who reached maturity were analysed. Time to union was 7.6 months. Union rate 70%. External fixation group: 7 patients, age 6.1 years, all united, 1 needed Bone graft. Average union time 8.2 months, no residual mal-alignment, no amputations, 2/7 needed corrective osteotomies and residual LLD in 2/7 < 1 cm. Numbers of surgery was 3. Vascularized fibular graft was done in 3 cases; all had failed previous attempts. Union time was 7 months. 2/3 united, 1 had amputation due to extensive disease. All patients had residual mal-alignment. Rodding group included 13 patients, age 3.2 years, union rate 61%, union time 8.3 months. Average LLD 1 cm with 1 patient LLD > 2 cm. Residual knee mal-alignment in 2/13, 4 had procurvatum and 55% of patients had ankle valgus. Fibula pseudoarthrosis. Refracture was reported in 53% of the rodding group. The causes of refracture were mal-alignment in 3, traumatic in 2 and idiopathic in 2. Total surgeries no 5. 2 patients had amputations after an unsuccessful 1. st. attempt. Our current trend of treatment was applied on 8 patients. They are not skeletally mature yet. the treatment combined excision of hamartoma, tibial rodding, wrapped periosteal graft with/out neutralization frame, and fibular fixation. Average age 3.8 years, union time was 10 months, Union rate 80%, no residual deformities. Conclusions. Our study shows the evolution of the treatment of CPT with increasing union rate, fewer residual deformities, and numbers of surgeries with more recent techniques

INTRODUCTION. Combining novel diverse population-based software with a clinically-demonstrated implant design is redefining total hip arthroplasty. This contemporary stem design utilized a large patient database of high-resolution CT bone scans in order to determine the appropriate femoral head centers and neck lengths to assist in the recreation of natural head offset, designed to restore biomechanics. There are limited studies evaluating how radiographic software utilizing reference template bone can reconstruct patient composition in a model. The purpose of this study was to examine whether the application of a modern analytics system utilizing 3D modeling technology in the development of a primary stem was successful in restoring patient biomechanics, specifically with regards to femoral offset (FO) and leg length discrepancy (LLD). METHODS. Two hundred fifty six patients in a non-randomized, post-market multicenter study across 7 sites received a primary cementless fit and fill stem. Full anteroposterior pelvis and Lauenstein cross-table lateral x-rays were collected preoperatively and at 6-weeks postoperative. Radiographic parameters including contralateral and operative FO and LLD were measured. Preoperative and postoperative FO and LLD of the operative hip were compared to the normal, native hip. Clinical outcomes including the Harris Hip Score (HHS), Lower Extremity Activity Scale (LEAS), Short Form 12 (SF12), and EuroQol 5D Score (EQ-5D) were collected preoperatively, 6 weeks postoperatively, and at 1 year. RESULTS. The mean age is 62 years old (range 32 – 75), 136 male and 120 female, BMI 29.7. The preoperative FO and LLD of the operative hip were 43.5 mm (±9.0 mm) and 3.0 mm (±6.5 mm) compared to the native contralateral hip, respectively. The postoperative FO and LLD were 46.4 mm (±8.7 mm) and 1.6 mm (±7.6 mm) compared to the native contralateral hip, respectively. The change in FO on the operative side was 3.0 mm (±7.2 mm) (p<0.0001) and the change in LLD from preoperative to 6-weeks postoperative was 1.6 mm (±8.4 mm) (p=0.0052) (Figure 1), demonstrating the ability of this stem design to recreate normal hip biomechanics in this study. The HHS increased considerably from a preoperative score of 55.9 to 78.4 at 6 weeks and 92.7 at 1 year. Clinically significant improvements were also seen at 1 year in the LEAS (+2.3), SF12 PCS (+16.3), and EQ-5D TTO (+0.26) and the EQ-5D VAS (+15.7). DISCUSSION and CONCLUSION. This study demonstrated that recreation of normal anatomic leg length and offset is possible by utilizing a modern fit and fill stem that was designed by employing an advanced anthropomorphic database of CT scans. We hypothesize that when surgeons utilize this current fit and fill stem design, it will allow them to accurately recreate a patient's natural FO and leg length, assisting in the restoration of patient biomechanics. Summary Sentence. In this study, modern design methods of a press-fit stem using 3D modeling tools recreated natural femoral offset and leg length, assisting in the restoration of patient biomechanics

Introduction. Limb length discrepancy after THA can result in medicolegal litigation. It can create discomfort for the patient and potentially cause back pain or affect the longevity of the implant. Some patients tolerate the length inequality better compared to others despite difference in anatomical femoral length after surgery. Methods and materials. We analyzed the 3D EOS images of 75 consecutive patients who underwent primary unilateral THA (27 men, 48 women). We measured the 3D length of the femur and tibia (anatomical length), the 3D global anatomical length (the sum of femur and tibia anatomical lengths), the 3D functional length (center of the femoral head to center of the ankle), femoral neck-shaft angle, hip-knee-ankle angle, knee flexum/recurvatum angle, sacral slopes and pelvic incidence. We correlated these parameters with the patient perception of the leg length. Results. The values for leg length and pelvic parameters are shown in table 1. 37 patients had a perception of the LLD (49.3%). When the global anatomical length was shorter on the operated side, the perception of the discrepancy was observed in 56% of the cases. In case of anatomical length longer on the operated side, the perception of the discrepancy was described by the patients in 46% of the cases. The LLD perception was correlated with difference in functional length (p=0.0001), pelvic obliquity (p=0.003) and sacral slope (p=0.023). The anatomical femoral length was not correlated with the LLD perception (p=0,008). Discussion. The perception of LLD is a multifactorial complication. We found that the anatomical femoral length (that can be directly affected by the position of the stem) is not the only important factor. The functional length of the lower extremity which can also be affected by the knee deformities is better correlated with the LLD. The pelvic obliquity and version also affect the patient perception of the LLD

Introduction. Many authors have described component position and leg length discrepancy (LLD) after total hip arthroplasty (THA) as the most important factors for good postoperative outcomes. However, regarding the relationships between component position and different approaches for THA, the optimal approach for component position and LLD remains unknown. The aims of this study were to compare these factors among the direct anterior, posterolateral, and direct lateral approaches on postoperative radiographs retrospectively, and determine which approach leads to good orientation in THA. Methods. We retrospectively evaluated 150 patients who underwent unilateral primary THA in our department between January 2009 and December 2014, with the direct anterior, posterolateral, or direct lateral approach used in 50 patients each. Patients with significant hip dysplasia (Crowe 3 or 4), advanced erosive arthritis, prevented osteotomy of the contralateral hip, and body mass index (BMI) of more than 30 were excluded. The mean age, sex, and preoperative diagnosis of the affected hip were equally distributed in patients who underwent THA with the different approaches. The mean BMI did not differ significantly among the groups. The radiographic measurements included cup inclination angle, dispersion of cup inclination from 40°, and LLD on an anteroposterior pelvic radiograph, and cup anteversion angle and dispersion of cup anteversion from 20° on a cross-table lateral radiograph postoperatively. We also measured the ratios of patients with both cup inclination of 30–50° and cup anteversion of 10–30° (target zone in our department), femoral stem varus/valgus, and LLD of 10 mm or less. Statistical analyses used an unpaired t-test and Fisher's exact test, with significance set at p<0.05. Results. The mean cup inclination was 36.9±5.1° for direct anterior approach, 40.8±7.5° for posterolateral approach, and 38.5±7.5° for direct lateral approach. Dispersion of cup inclination from 40° was almost identical in the three groups, with no significant differences. The mean cup anteversion was 23.4±5.5° for direct anterior approach, 25.9±9.2° for posterolateral approach, and 24.3±8.6° for direct lateral approach. Dispersion of cup anteversion from 20° differed between direct anterior approach and posterolateral or direct lateral approach (P<0.05 for each). The mean LLD was 1.3±6.6mm for direct anterior approach, 3.0±8.6mm for posterolateral approach, and 2.6±7.4mm for direct lateral approach. The mean LLD did not differ significantly among the three groups. The ratio of patients with both cup inclination of 30–50° and cup anteversion of 10–30° was significantly better for direct anterior approach than for posterolateral or direct lateral approach (78% vs. 52% and 52%, respectively; p<0.05). The ratios of femoral stem varus/valgus and LLD of 10 mm or less did not differ among the groups. Conclusions. The direct anterior approach in THA appeared to have small dispersion of cup anteversion angle and high ratio of cup component position in our target zone compared with the posterolateral and direct lateral approaches. However, the LLD and femoral stem varus/valgus after THA did not differ significantly among the three approaches postoperatively

Introduction. Intramedullary lengthening devices have been in use in older children with closed /open growth plates with good success. This study aims to present the early experience of the FITBONE nail since withdrawal of the PRECICE nail. Materials & Methods. Retrospective analysis of both antegrade and retrograde techniques were utilized. Only patients where union was achieved and full weight bearing commenced were included. The complication rate, length gained, distraction index, weight bearing index (WBI) as well as mechanical axes were analysed. Results. 14 (7 males, 7 females) of a total of 16 (7 males, 7 females) patients with a mean age of 16.9 years with varied diagnosis of LLD were analysed. The mean length gained was 38 mm with an average distraction index of 0,74 mm/day. WBI in these patients on average was 59,6 days/cm lengthened. 6 complications were observed, including two nonunions (successfully treated) and a knee subluxation. Mechanical axis deviation improved from 13,3 mm to 6 mm on average. Overall there has been a nonsignificant tendency for WBI to decrease (Spearman's rank correlation coefficient −0.47, p=0.08) with increasing number of cases done, while no correlation between length gained and WBI (−0.01, p=0.96, respectively) was observed. Some nuances will be discussed. Conclusions. Limb lengthening with the FITBONE nail is relatively safe and efficient, however no significant change was seen in the outcome with previous motorized nails

Background:. Total hip arthroplasty (THA) has been proven to be successful in achieving adequate pain relief and favorable outcomes in patients suffering from hip osteoarthritis (OA). However, leg length discrepancy (LLD) is still a significant cause of morbidities such as nerve damage, low back pain and abnormal gait. Despite most of the reported values of LLD in the literature being within the acceptable threshold of < 10 mm, some patients still report dissatisfaction, leading to litigation against orthopedic surgeons. However, lower extremity lengthening is sometimes necessary to achieve adequate hip joint stability and prevent dislocations. The purpose of this study was to compare LLD in patients undergoing THA using three different techniques: conventional anterior-approach THA (ATHA), conventional posterior-approach THA (PTHA), and robotic-assisted posterior-approach THA (RTHA) using the MAKO™ robotic hip system. Materials and Methods:. All cases of RTHA, ATHA and PTHA that were performed by the senior surgeon between Sep 2008 and Dec 2012 were reviewed. Patients included in this study had a primary diagnosis of hip osteoarthritis, with available and proper post-operative antero-posterior pelvis radiographs. All radiographs were calibrated and measurements done twice by two blinded observers. Results:. After exclusions, 67 RTHA cases, 29 ATHA cases and 59 PTHA cases were included in this study. There was a strong inter- and intra-observer correlation for all LLD measurements (r > 0.9, p < 0.001 in all). Mean LLD in the RTHA, ATHA and PTHA groups was 2.7 ± 1.8 mm (CI. 95. : 2.3, 3.2), 1.8 ± 1.6 mm (CI. 95. : 1.2, 2.4) and 1.9 ± 1.6 mm (CI. 95. : 1.5, 2.4) respectively (p = 0.01). When LLD > 3 mm was set as an outlier, the percentage of patients in the RTHA, ATHA and PTHA groups was 37.3%, 17.2% and 22% respectively (p value range, 0.06–0.78). When LLD > 5 mm was set as an outlier, the percentage of patients in the RTHA, ATHA and PTHA groups was 10.4%, 6.9% and 8.5% respectively (p value range, 0.72–1.0). None of the patients in all three groups had LLD ≥ 10 mm (Figure 1). Conclusion:. The results of the current study demonstrate the accuracy of the MAKO™ system in obtaining minimal LLD compared to the conventional anterior-approach and conventional posterior-approach THA, with no cases having LLD > 10 mm

Objective. In total hip arthroplasty (THA), the femoral component influences leg length inequality and gait, and is associated with poor muscle strength and other unsatisfactory long-term results. We have therefore used intraoperative radiographs to acquire accurate measurements of femoral component size and position. At the last meeting of this society, we reported that accurate positioning was successfully achieved in 68 cases (87.2%) as a consequence of taking intraoperative radiographs. However, we have little understanding as regards to the accuracy of X-ray measurements. We accordingly undertook an examination of the accuracy of such measurements. The purpose of this study was to evaluate the difference between leg length discrepancy (LLD) measured using X-ray and computed tomography (CT). Materials and Methods. The study group comprised 48 primary THAs performed between October 2010 and April 2012. Using 2D template software (JMM Corporation), we measured LLD using pre-operative anteroposterior (AP) radiographs of the pelvis. On the basis of both teardrop lines, we measured LLD of the lesser trochanter top (Fig. 1), lesser trochanter direct top (Fig. 2), and trochanteric top (Fig. 3). Furthermore, using Aquarius NET software, we measured LLD using AP and lateral scout views of the pelvis and bilateral femurs. This data was defined as the true LLD. The difference between the X-ray data (lesser trochanter top, lesser trochanter direct top, and trochanteric top) and the CT data was defined as accuracy. Additionally, we measured the size of the lesser trochanter and examined the association. Results. The mean LLD was 11.4, 12.1, and 9.6 mm on the lesser trochanter top, the lesser trochanter direct top, and the trochanteric top of radiographs, respectively, and 11.6 mm on CT scans. Precision was within 5 mm of the true LLD in 42 cases (87.5%) for the lesser trochanter top, 36 cases (75.0 %) for the lesser trochanter direct top, and 27 cases (63.0%) for the trochanteric top. We observed no association between the size of the lesser trochanter and the measurement accuracy. Conclusions. When using X-ray measurements, the lesser trochanter top is the most useful site for LLD measurement

Introduction. Legg-Calve-Perthes disease (LCPD), a juvenile osteonecrosis of the femoral head (ONFH), can remain sequelae around hip joint, and results in osteoarthritis necessitating total hip arthroplasty (THA) in middle-age. THA for sequelae of LCPD needs specific concerns for anatomical deformity, leg length discrepancy (LLD), and relatively young patient's age. To date, few studies are available for the results of THA for LCPD sequelae. Moreover, there was no study for the result of Alumina-Alumina THA (Al-Al THA) in patient with LCPD sequelae, even excellent long term outcome of Al-Al THA has been documented in relatively young patients. The aim of this retrospective study is to evaluate the clinical and radiological outcome of Al-Al THA for LCPD sequelae, especially in terms of the restoration of LLD and the occurrence of complication. In addition, we compared the results of THA for LCPD sequelae with those for adult onset ONFH, in which THA is necessitated in relatively young age and excellent long term outcome has been proven after Al-Al THA. Method. Between 1997 and 2007, 41 cementless Al-Al THA were performed in 37 patients with LCPD sequelae and followed up for mean, 10.4 years. Mean age at THA was 43.6 years. Using the propensity score matching with age, gender, and the length of follow-up as variables, 41 THAs in 37 patients were identified from 339 hips in 256 patients who underwent primary Al-Al THA for ONFH during the same period. Clinical and radiological outcomes in terms of implant survival, Harris hip score (HHS), LLD change, and perioperative complication were compared between the two groups. Results. In LCPD group, there was no revision during follow-up period. All stems and cups were survived without osteolysis or loosening at last follow-up. HHS increased significantly from 70.9±12.9 point to 97.4±5.4 point (p<0.001). LLD decreased significantly from 2.0±1.2 cm to 0.2±0.9 cm. (p<0.001). Fourteen intraoperative femoral cracks occurred. One patient showed peroneal nerve palsy after surgery. There was one patient with deep vein thrombosis without pulmonary embolism. In ONFH group, there was also no revision during follow-up and all implant was radiologically stable without evidence of osteolysis or loosening. HHS increased significantly from 44.9±21.4 point to 96.6±4.6 point (p<0.001). LLD decreased significantly from 0.5±0.8 cm to 0.1±0.9 cm. There were 6 intraoperative femoral fractures. Also, there was 2 more postoperative periprosthetic fractures after trauma and 1 postoperative dislocation. Even the implant survival was not different between two groups, LCPD group showed higher rate of overall complication (p=0.04) and intraoperative femoral fracture (p=0.027) than ONFH group. Conclusion. Outcomes of Al-Al THA in patients with sequelae of LCPD were comparable to those in patients with ONFH clinically and radiologically. LLD was restored after THA without troublesome neurologic complication in both groups. Although high rate of intraoperative femoral crack was revealed in LCPD group, fracture union was achieved in all hips without stem loosening. As with ONFH, Al-Al THA may be a reliable treatment option for the patients with LCPD sequelae

Introduction. To minimize leg length discrepancies (LLD), preoperative measures are taken using the PACS; the head center to the proximal end of the lesser trochanter distance (HLD) of the opposite side of the operating limb are calculated, while during operation, the modular neck selection is adapted to equal the opposing limb's length. The purpose of this study was to see whether the HLD method would show far less occurrences of LLD, in comparison to the conventional method(preoperative templating and shuck test). Method. 349 (412 hips) patients who had undergone THRA were divided into two groups based upon which methods they had used to equalize limb length during operation: (1) HLD method, and (2) conventional methods. Six months after surgery, using the PACS system, LLD's of the two groups were compared. Results. The mean postoperative LLD was 2.6±4.2 (0–15) mm in the HLD group and 5.2±7.0 (0–23) mm in the conventional group. In the HLD group, 81% (174/215) of the hips had LLD < 6 mm after surgery versus 72% (141/197) of the hips in the conventional group (P < 0.038). The mean Harris hip score (HHS) after THA improved from 47.2 to 93.3 in the HLD group and 46.8 to 91.8 in the conventional group. Discussion. Statistically, there was a significant difference of LLD between the two groups (p=0.038). HLD method, which is non-invasive and simple, would minimize LLD after total hip arthroplasty

Introduction. Infected big gap non-union of femur and tibia are difficult to treatment because of infection, bone loss, shortening, poor sift tissue over and deformity. Step by step management and definitive treatment by Ilizarov fixator was achieved in our cases. Materials and Methods. A long defect which is more than 10cm in femur and tibia because of infection and gap, tumor resection, traumatic loss, which is very difficult to treat by conventional method and that's why we treated that type defect by Tibialization of fibula with Ilizarov technique. Management of infected big gap non-union of the femur include debridement and bone transport by Ilizarov technique by using Ilizarov fixator we can correct deformities, regenerate new bone without bone grafting, correct LLD and patient can weight bear during the course of treatment. We retrospectively reviewed records of 246 consecutive patients who underwent distraction osteogenesis using Ilizarov compression-distraction device for infected big gap INU of femur and tibia from 2000 to 2020. Results. All healed with the application of Ilizarov fixator, 5 needed reapplications of Ilizarov to achieve 100% union. 210 were excellent, 25 good and 6 were fair by ASAMI criteria. Mean Ilizarov duration was 366 days (130–250). Mean 8.2 cm length was achieved in the regenerate. Conclusions. A well plan step by step Ilizarov technique to cover infected gap non-union of femur and tibia is an excellent method in challenging cases. Excellent results cannot be achieved with conventional methods but can be easily achieved with Ilizarov technique within 1–2 years