Digital templating was used in 50 patients who underwent THA using Merge Ortho software, Cedara. Clinical examination was performed first, to measure leg lengths and account for pelvic obliquity and flexion deformity. Good quality digital radiographs were obtained with anteroposterior and lateral views extending beyond the tip of the femoral component and the cement restrictor. A coin was placed on the ASIS to help in determining radiological magnification. Digital radiographs were saved in DICOM format and imported to EndoMap software system. A 6-step technique was used for templating as follows:. Radiographic assessment; looking at the quality of bone, amount of bone stock, dysplasia, osteophytes, and other abnormalities. Correction of magnification; following the specific instructions of the software, by measuring the diameter of the coin on the digital radiograph. 3. Measuring leg length discrepancy; the software system automatically calculated the leg length discrepancy, even in the presence of pelvic obliquity (Figure1). 4. Templating acetabular component; the desired cup was selected from the implant library after identifying important landmarks. The size and position was modified to fit the acetabulum and to restore the center of rotation of the hip, considering minimal bone removal and sufficient bone coverage laterally. Templating femoral component; the size and position of the desired stem was adjusted to fit the femoral canal, different offsets were compared to find the best match for the patient's original offset. Correction of leg length discrepancy and measuring length of neck resection; the height of the femoral stem was adjusted to correct any leg length discrepancy by placing the center of the head above the center of the cup by the same length of discrepancy. Then the level of the neck resection was marked at the level of the stem collar and the femoral neck cut was measured by a digital ruler from the tip of the lesser trochanter to the mark of neck resection. In case of leg length discrepancy, the height of the femoral neck cut was adjusted accordingly to compensate for the leg length discrepancy. For example, if the affected leg is 20 mm short, place the centre of the head 20 mm above the centre of the cup. Intraoperatively, the surgeon performed the femoral neck osteotomy at the level determined by preoperative templating. Postoperatively, the leg length was measured and compared to the preoperative leg length. Preoperatively, the leg length discrepancy ranged from 5 to 30 mm. In all cases, the leg was short on the side of THR (ipsilateral). Leg length discrepancy was adjusted in all THR cases. Postoperatively, the accuracy of the correction was found to be within 5 millimeters i.e. less than 5mm of shortening or lengthening). Intraoperatively, the level of femoral neck cut ranged from 1 to 44 mm. Digital templating is useful in adjusting leg length discrepancy. In addition, there were other benefits such as predication of femoral and acetabular implant sizes, restoration of normal hip centre, and optimization of femoral offset

The Dall approach is a modified anterolateral approach with osteotomy of the anterior part of the greater trochanter. This approach relatively preserves the soft tissue tension during total hip arthroplasty (THA). We insert the stem and select a ball neck size so as to have a stable hip which will not dislocate easily during the trial reduction. The aim of this study is to evaluate the adequacy of this method, to measure leg length discrepancy and offset discrepancy at postoperative radiographs. We selected patients for inclusion in this study from those who have more than a 120 degree of affected hip flection angle, the opposite hip is almost normal with a low leg length discrepancy (primary OA, osteonecrosis, Crowe 1 secondary OA, femoral neck fracture). All THA were performed with cement fixation using an alignment guide to ensure accurate acetabular positioning. The ball head's diameter used were all 26mm. From September 2011 to October 2013, 22 patients met inclusion criteria among 103 THA. The mean age for 22 subjects was 66.6±12 years. The mean flexion angle of preoperative hip joints was 127.2±6.1 degrees. The cup inclination was 43.8° ± 3.5°. Anteversion was 11.8°±6°. The mean preoperative leg length discrepancy was 5.8mm±6.3mm. The mean postoperative leg length discrepancy was 0.7±3.5mm. The mean postoperative offset discrepancy was 0.7±6.6mm. There were no dislocations in this series of 103 cases. Discussion. Dislocation and leg length discrepancies are major complications following a total hip arthroplasty. A good range of motion of the preoperative hip joint is considered a high risk dislocation factor. The Dall approach with minimal release of soft tissue related to a tension of hip joint offers maximal stability and the ability to accurately restore leg length

Our aim was to use CT Scanogram to evaluate fibular growth, and thus calculate normal growth velocity, which may aid in determining the timing of epiphysiodesis. Current understanding of normal lower limb growth and growth prediction originates in the work of Anderson et al published in the 1960s. There now exist several clinical and mathematical methods to aid in the treatment of leg length discrepancy, including the timing of epiphysiodesis. Early research in this area provided limited information on the growth of the fibula. It is now well recognized that abnormal growth of paired long bones may evolve into deformity of clinical significance. Existing work examining fibular growth used plain film radiography only. Computed Tomography (CT) scanogram is now the preferred method for evaluating leg length discrepancy in the paediatric population. We calculated fibular growth for 28 children (n = 28, 16 girls and 12 boys) presenting with leg length discrepancy to our unit. Mean age at presentation was 111.1 months (range 33 – 155 months). For inclusion, each child had to have at least five CT scanograms performed, at six monthly intervals. Fibular length was calculated digitally as the distance from the proximal edge of the proximal epiphysis to the most distal edge of the distal epiphysis. For calculation purposes, mean fibular length was determined from two measurements taken of the fibula. A graph for annual fibular growth was plotted and fibular growth velocity calculated. CT Scanogram may be used to calculate normal fibular growth in children presenting with leg length discrepancy

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

Background. Leg length discrepancy (LLD) after intramedullary nailing of femoral shaft fractures is a common problem reported in up to 43% of cases. Comminuted fractures with radiographic loss of bony landmarks have an increased possibility of being fixed with unequal leg lengths. Aims. The purpose of this report is to evaluate the efficacy of routinely obtaining a CT scanogram post-operatively on patients of comminuted femoral shaft fractures treated with intramedullary nailing and immediate correction of limb length inequality if indicated. Results. Twenty one patients with comminuted femoral shaft fractures that were treated with intramedullary nailing and underwent a CT scannogram for evaluation of LLD were included in the study. There were 12 patients with Winquist III and 9 with a Winquist IV fracture pattern. Following surgery leg lengths were measured from the CT scanograms using a computerised measuring ruler. The largest leg length discrepancy noted on scannogram was 4 cm. The average limb length discrepancy was 0.67 cm. Eight patients had a discrepancy of 1cm or greater. We also measured the tibial length in all patients and found only 3 patients with exactly equal tibial lengths. A tibial length discrepancy less than 5mm was observed in 11 patients. In 7 patients it was between 5-9mm and in 3 patients it was 10mm or greater. Four patients underwent leg length correction during the same admission. Conclusion. The decision to undertake correction of the LLD is primarily dependant on the degree of discrepancy. The degree of LLD that requires correction remains undefined. In this study LLD of greater than 15mm was considered for equalisation. Immediate equalisation saves cost, morbidity, delayed sequelae and litigation. Tibial length discrepancy may contribute to the total leg length discrepancy and requires consideration. We recommend a post-operative scanogram costing $380 in patients of comminuted femoral shaft fractures treated with intramedullary nailing

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

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

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

Aims

Leg length inequality following total hip replacement remains common. In an effort to reduce this occurrence, surgeons undertake pre-operative templating and use various forms of intra-operative measurements, including computer navigation. This study aims to delineate which measurement technique is most appropriate for measuring leg length inequality from a pelvic radiograph.

Acetabular cup positioning remains a real challenge and component malpositioning after total hip arthroplasty (THA) can lead to increased rates of dislocation and wear. It is a common cause for revision THA. A novel 3D imageless mini-optical navigation system was used during THA to provide accurate, intraoperative, real-time, and non-fluoroscopic data including component positioning to the surgeon. This retrospective comparative single surgeon and single approach study examined acetabular component positioning between traditional mini-posterolateral THA and mini-posterolateral THA using the 3D mini-optical navigation system. A retrospective chart review was conducted of 157 consecutive (78 3D mini-optical navigation and 79 traditional non-navigation methods) THAs performed by the senior author using a mini-posterolateral approach at an ambulatory surgery center and hospital setting. Two independent reviewers analyzed postoperative radiographs in a standardized fashion to measure acetabular component positioning. Demographic, clinical, surgical, and radiographic data were analyzed.

These groups were found to have no statistical difference in age, gender, and BMI (Table I). There was no difference between groups in acetabular components in the Lewinnek safe zone, 31.2% vs 26.6% (p = 0.53). Cup anteversion within the safe zone did not differ, 35.1% vs 40.5% (p = 0.48); while cup inclination within the safe zone differed, with more in the navigation group, 77.9% vs 51.9% (p < 0.01). Change in leg length was significantly different with the navigation group's leg length at 1.9 ± 6.3, less than the traditional at 5.4 ± 7.0 (p < 0.01). There was no difference in mean change in offset between groups (4.5 ± 5.9 vs 6.2 ± 7.9, p = 0.12); navigation, traditional) (Table II). The 3D mini-optical navigation group did have significantly longer operative time (98.4 ± 17.5 vs 89.3 ± 15.5 p < 0.01). Use of the novel 3D Mini-optical Navigation System significantly improved cup inclination compared to traditional methods while increasing operative time.

For any figures or tables, please contact the authors directly.

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

Introduction. Reconstruction of large defect of tibia following infection is considered as one of the most difficult problem facing the orthopaedic surgeon. Amputation with modern prosthetic fitting is a salvage procedure to treat big defects, which gives a functional result with unpredictable psychological impact. Materials & Methods. Between January 2000 and January 2021, 56 patients (30 males and 26 females) with big defects following infection and post traumatic injury of the tibia were treated. The mean age of the patients at the time of surgery was 20.5 years (4–24 years). The fibula was mobilized medially to fill the defect and was fixed with Ilizarov fixator. The average size of the defects reconstructed was 18.5 cm (17–20 cm). Results. The average time for complete union was 8.6 months (range, 5–9 months). At final follow-up all patients had fully united. We found leg length discrepancy in 52 patients and that was corrected by re-lengthening of the solid new regenerate bone. Conclusions. The Ilizarov method has been shown to be an effective method of treating Tibialization of fibula for reconstruction of big tibial defects

Dislocation is one of the most common complications in total hip arthroplasty (THA) and is primarily driven by bony or prosthetic impingement. The aim of this study was two-fold. First, to develop a simulation that incorporates the functional position of the femur and pelvis and instantaneously determines range of motion (ROM) limits. Second, to assess the number of patients for whom their functional bony alignment escalates impingement risk. 468 patients underwent a preoperative THA planning protocol that included functional x-rays and a lower limb CT scan. The CT scan was segmented and landmarked, and the x-rays were measured for pelvic tilt, femoral rotation, and preoperative leg length discrepancy (LLD). All patients received 3D templating with the same implant combination (Depuy; Corail/Pinnacle). Implants were positioned according to standardised criteria. Each patient was simulated in a novel ROM simulation that instantaneously calculates bony and prosthetic impingement limits in functional movements. Simulated motions included flexion and standing-external rotation (ER). Each patient's ROM was simulated with their bones oriented in both functional and neutral positions. 13% patients suffered a ROM impingement for functional but not neutral extension-ER. As a result, 48% patients who failed the functional-ER simulation would not be detected without consideration of the functional bony alignment. 16% patients suffered a ROM impingement for functional but not neutral flexion. As a result, 65% patients who failed the flexion simulation would not be detected without consideration of the functional bony alignment. We have developed a ROM simulation for use with preoperative planning for THA surgery that can solve bony and prosthetic impingement limits instantaneously. The advantage of our ROM simulation over previous simulations is instantaneous impingement detection, not requiring implant geometries to be analysed prior to use, and addressing the functional position of both the femur and pelvis

Introduction. The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. Materials & Methods. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome. Results. The mean defect size after tumour resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale(MSTS) score of the evaluable 9 patients was 85% (57% to 100%)with good or excellent results in 7 patients. Conclusions. A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of com-plications requiring surgical intervention, even though most were not serious

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. At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022. Materials & Methods. The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented. Results. There were 8 males, mean age 17.4 years (range 17–18) and 8 females, mean age 15.9 years (range 14–18). 5 right and 11 left femurs were lengthened. Underlying pathology varied amongst the 16 patients. All patients went into a hinged knee brace post operatively. Structural limitations included: pain, fixed flexion deformity of the knee, loss of knee flexion, quadriceps muscle lag, muscle spasms and gluteal weakness. The primary activity limitation was reduced weight bearing with altered gait pattern. Participation limitations included reduced school attendance and involvement in activities with peers. Access to Physiotherapy from local services varied dramatically. Five of the cohort have completed treatment. Conclusions. Anecdotally, intramedullary femoral lengthening nails have perceived benefits for families compared to external fixators in the adolescent population. However, there remain musculoskeletal and psychosocial outcomes requiring therapeutic management throughout the lengthening process and beyond. Therefore, quantifying these outcomes is essential for measuring the impact on each patient for comparison. To interpret these themes, we need to evaluate the outcomes objectively, this was not done consistently in this review. Future research should look at outcome measures that are sensitive to all aspects of the ICF. With an aim of improving the therapeutic treatment provided and the overall outcome for the children treated

Background. Postoperative dislocation is one of the main surgical complications and the primary cause for revision surgery after 2-stage implant exchange due to periprosthetic infection of a total hip arthroplasty. Objective. The aims of our study were (1) to determine the incidence of dislocation after two-stage THA reimplantation without spacer placement, (2) to evaluate relevant risk factors for dislocation and (3) to assess the final functional outcome of those patients. Method. We prospectively analyzed 187 patients who underwent a two-stage total hip arthroplasty (THA) revision after being diagnosed with periprosthetic joint infection (PJI) from 2013 to 2019. The mean duration of follow-up was 54.2 ± 24.9 months (>36 months). The incidence of postoperative dislocation and subsequent revision was estimated through Kaplan-Meier curves and potential risk factors were identified using Cox hazard regression. The functional outcome of the patients was assessed using the modified Harris Hip Score (mHHS). Results. The estimated cumulative dislocation-free survival was 87.2% (95% CI: 81.2%-91.3%) with an estimated 10% and 12% risk for dislocation within the first 6 and 12 months, respectively. The use of a dual-mobility construct had no significant impact on the dislocation rate. Increasing body mass index (BMI) (HR=1.11, 95% CI: 1.02-1.19, p=0.011), abductor mechanism impairment (HR=2.85, 95% CI: 1.01-8.01, p=0.047), the extent of elongation of the affected extremity between stages (HR=1.04, 95% CI: 1.01-1.07, p=0.017), the final leg length discrepancy (HR=1.04, 95% CI: 1.01-1.08, p=0.018) and PJI recurrence (HR=2.76, 95% CI: 1.00-7.62, p=0.049) were found to be significant risk factors for dislocation. Overall revision rates were 17% after THA reimplantation. Dislocated hips were 62% more likely to undergo re-revision surgery (p<0.001, Log-rank= 78.05). A significant average increase of 30 points in mHHS scores after second-stage reimplantation (p=0.001, Wilcoxon-rank) was recorded, but no difference was noted in the final HHS measurements between stable and dislocated hips. Conclusion. Dislocation rates after 2-stage THA reimplantation for PJI remain high, especially regarding overweight or re-infected patients. Careful leg length restoration and an intact abductor mechanism seem critical to ensure stability in these complex patients

Introduction. While research has been carried out widely for sagital pelvic tilt, research reports for coronal pelvic obliquity are few. The aim of this study is to evaluate changes of the pelvic obliquity before and after total hip arthroplasty. Material and Methods. This retrospective study includes 146 cases of hips that were received total hip arthroplasty. There were 20 cases of revision, and 2 cases of re-revision. 17 cases were received bilateral total hip arthroplasty. The standing plain X-ray was used for evaluation of the pelvic obliquity in both before and 1-year after surgery. The correlation of pelvic obliquity was assessed between before and after surgery. 146 cases were classified into 3 groups (A, B, and C) according to the severity of the pelvic obliquity (0º−3º, 3º−6º, and >6º). Among the groups, statistical analysis was evaluated in the leg length discrepancy and the range of motion of the hip (flexion, extension, abduction, adduction, internal and external rotation) before and after surgery with 95% confidence intervals. Results. The mean pelvic obliquity angle was 2.6º with the range of 0 to 15.9º preoperatively, while the mean angle was 2.0º with the range of 0 to 8.8º postoperatively. There was statistical correlation in pelvic obliquity between before and after surgery. The mean leg length discrepancy was −8.3 before surgery, and was 0.1 after surgery. Comparing three groups of pelvic obliquity, preoperative leg length discrepancy was significantly longer in larger pelvic obliquity groups. The range of motion in hip flexion was also significantly smaller in larger pelvic obliquity groups. There were not significant differences in postoperative leg length discrepancy and other parameters. Discussion. The most important finding of present study was that postoperative pelvic obliquity related only the preoperative leg length discrepancy and the range of motion in hip flexion. We expected that pelvic obliquity is improved by correction of leg length difference. Nevertheless, there were not significant differences in postoperative leg length discrepancy. This indicated that contracture of the hip joint is contribute to pelvic obliquity more than leg length discrepancy. Previous study reported that pelvic obliquity would be improved by physical therapy 4 to 6 month after surgery. However, in our data, pelvic obliquity still remained at 1-year follow up. Moreover, postoperative pelvic obliquity related the preoperative range of motion in hip flexion. Therefore, preoperative pelvic obliquity is one of the most important parameter to make decision of postoperative leg length discrepancy. There is certain limitation in our study. We did not assess patient outcome in each groups. Extensive studies are needed to reveal correlation between pelvic obliquity and patient outcome. Conclusion. Pelvic obliquity related the preoperative leg length discrepancy and the range of motion in hip flexion. Contracture of the hip joint may cause pelvic obliquity

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. Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. Methodology. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct. Results. Three children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18. o. (10–38. o. ) with pre-op coxa vara FNSA av. 99. o. (range 87–114. o. ) and final FNSA 117. o. (105–125. o. ). Hilgenreiner's epiphyseal angle was improved by av. 29. o. (2–58. o. ). However only one hip was restored to <25. o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required. Conclusions. Surgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up