Background. Exeter Trauma Stem (ETS) is a polished tapered collarless monopolar prosthesis used for cemented hemiarthroplasty for fracture neck of femur. Two modular rasps are available on the instrumentation set. The larger rasp, in practice, rarely fits into the femur making trial reduction impossible. Our hypothesis was that the absence of a trial reduction could affect leg length and stability of the prosthesis. Aim. To evaluate the leg length discrepancy following use of Exeter Trauma Stem for intracapsular fracture neck of femur. Methods. All patients who underwent ETS hemiarthroplasty between June 2009 to March 2010 (n = 100) were included in the study. Radiographic assessment of leg length was performed by two independent assessors based on measurements by Woolson et al. Results. Upto half of the patients had equal leg length measurements. Forty four patients had lengthening of the operated leg with a mean of 10mm (5–25). Further complications included four dislocations. There was no statistical significance between leg lengths and dislocations. Conclusion. Care is needed with regards to correct positioning of the ETS prosthesis to achieve equal leg lengths. Following this study a new intermediate sized modular rasp has been introduced to the instrumentation set

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

Introduction:. Paley et al has developed a multiplier method for calculating both leg length and total height. In the development of this algorithm, they evaluated the effect of factors including bone age and sex. They established that sex had a significant impact, but adjusting for bone age did not improve accuracy. Bone age and menarche have been shown to improve other height prediction models. Purpose:. We used a large prospective cohort to evaluate if the multiplier is independent of physiological age using menarche as a proxy. Methods:. Using the ALSPAC dataset we determined the accuracy of the Paley multiplier for predicting total height and leg length, and assed weather if the date of first menses increased the accuracy of the multiplier. Female patients over the age of 8, with documented final height and final sub-ishial leg length over the age of 15 and a date of first menses were evaluated. Predicted final height was compared with actual final height at all data points. Results:. There were 28332 data points in 3062 girls prior to skeletal maturity in the total height cohort and 8395 data points in 2300 girls in the leg length cohort. When age was corrected using the difference in age at onset of menarche from average, the accuracy of multiplier decreased for both measurements. When a correction of 50% was used, there was an improvement in the accuracy of multiplier predictions, reducing the average error by up to 24%. Conclusions:. Previous studies have failed to demonstrate that the accuracy of the multiplier is improved when adjusted for bone age. We have used the date of first menses as a proxy for bone age and established that making a 50% correction for physiological age improves the accuracy of this method. Significance:. This will potentially allow more accurate prediction of leg length discrepancy, and total height in girls with early menarche

Background:. Paley et al has developed the multiplier method for predicting leg length. It is a tool that is used clinically to predict leg length discrepancy. The method is also a way of comparing different populations, to identify differences in growth trajectory. This has been done by identifying the differing multipliers for girls and boys. However it has not been used to identify trends in populations separated by time. Tanner showed that in the first half of the twentieth century girls went from an average age of menarche of 15 in 1900, to 13 in 1970, how this has affected growth trajectory over the last 50 years has not been studied. Purpose:. The multiplier method is based on data collected in the 1950's by Anderson and Green, we aim to assess whether there has been a change in growth trajectory between this historical cohort and a contemporary European based cohort. Methods:. The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally, and followed prospectively. Assessment of sub ischial leg length was made on clinical measurements. There were up to 8 measurements per patient, 2311 girls with a final age at assessment of greater than 15 years and 123 males with a final age of assessment of greater than 16 years were assessed. We used the multiplier method to assess the predicted final leg length and compared this with the actual leg length. Result:. There was no difference between the multiplier in girls, in the contemporary cohort and the historical cohort. The average age of menarche in the contemporary group was 12.7. In boys the data is limited, due to later growth and it is not possible to draw comparisons from this group. Conclusion:. This data provides good evidence that there has not been a significant change in growth trajectory in girls over the last 50 years. Significance:. Implications on the confidence with which we can use the multiplier method in this population

Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery. The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems. This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification). 122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B. We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study

The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction. We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage. This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD. Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded. During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line. Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Aim. Our goals were to minimize the invasiveness of the revision hip arthroplasty approach in order to accelerate the patient's rehabilitation, shorten the length of hospitalization and reduce the postoperative complications, especially the rate of joint dislocation. Our study aimed to prove whether and under which conditions the less invasive approach is preferable in revision arthroplasty. Material and Methods. The modified revision technique differs from the conventional approach in the following main aspects:. Oncologic: applying larger hip balls and inserts, after expanding the variety of the available articulating joint components in 4 mm steps (28–40 mm),. sparing and reconstructing the joint capsule, whereby the integrity of its acetabular origin is crucial. That procedure was combined with tissue dissection strictly parallel to the direction of the muscle fibers. The transgluteal approach after Bauer was applied. The small skin incision was closed by running subcuticular technique. The inpatient postoperative phase after revision total hip arthroplasty was evaluated in the last 6.5 years. All patients completed a questionnaire. Results. Less invasive revision hip arthroplasty was performed in 55 cases in a period of 6.5 years. No intraoperative method-specific complication was observed. Only one dislocation and one early infection, which needed surgical intervention, were recorded. The mean postoperative length of stay was 9.5 days after less invasive revision hip arthroplasty compared to an average of 20.5 days for all revisions. The duration of inpatient treatment was thus halved. This technique was mostly applied in the isolated stem exchange, followed by exchange of bearing components and complete joint exchange. The isolated socket exchange with stable stem is, however, difficult to be realized in the less invasive technique. Conclusion. The less invasive revision hip arthroplasty is associated with a low complication rate. It can be applied in about 30–50% of revision cases. Reconstructing the integrity of the capsule represents the most important modification of the operation's technique. The postoperative joint stability is on the midterm increased and the reconstruction of leg length is indirectly facilitated compared to resecting the joint capsule. Applying larger ball-insert pairs depending on the outer diameter of the socket allows a long-term increase in the joint stability and thus a reduction in the dislocation risk. Owing to its low complication rate and significant reduction of the length of stay, the less invasive revision hip arthroplasty approach is medically and economically recommended

Total hip replacements have been shown to give superior outcomes in patients with intracapsular fractures of the neck of femur compared with hemiarthroplasty. Collarless uncemented femoral stems give excellent long term results in elective hip replacements but there are few studies looking at their outcomes in fractured neck of femur patients. There is some concern that in trauma patients bone quality maybe inferior as most neck of femur fractures are secondary to osteoporosis. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems and result in early subsidence, which can lead to altered leg length and decreased hip stability. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat patients with fractures of the neck of femur. Post-operative radiographs of 33 patients, mean age 71, who underwent an uncemented collarless total hip replacement for a fracture, were reviewed. The distance from the calcar to the tip of the prosthesis was measured for each patient on the initial post operative radiograph and again on the follow-up radiograph at 6 months post operation. Any subsidence was recorded and magnification for each radiograph was calculated by measuring the diameter of the femoral head, which was known to be 36mm. Distances were then adjusted for magnification. The same procedure was performed on 36 age-matched patients, mean age 71, who underwent elective uncemented total hip replacements for osteoarthritis. Hospital notes for each patient were reviewed to assess for complications and DEXA scan results for trauma patients were also evaluated where available. The mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p = 0.001) with mean subsidence of 4.07mm (range 0.02–18.5mm) and 1.57mm (range 0–5.5mm) respectively. In the fracture cohort there were 3 revisions within 6 months of surgery, 1 for infection and 2 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort. DEXA scan results were available for 21 of the 33 fracture cohort patients. All these patients had abnormal bone density with 52% being osteoporotic and 48% osteopenic. This study showed that collarless uncemented stems subsided significantly when performed for fractures and had a high early revision rate. We therefore recommend that cemented or collared femoral stems be used in patients with femoral neck fractures requiring total hip replacement to reduce the risk of femoral stem subsidence

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

Background

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Cite this article: Bone Joint J 2015;97-B:1417–22.

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5).

All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.

We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistant pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35).

Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.

Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient.

We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.