Introduction

Gaucher Disease (GD) is the commonest of the lysosomal storage disorders. Orthopaedic manifestations occur in 90% and include osteonecrosis of the femoral head, often producing severe disability at a young age. Historically, arthroplasty has been avoided in GD due to high reported rates of haemorrhage and decreased implant survival. The advent of enzyme replacement therapy (ERT) has revolutionised GD treatment with correction of haematological parameters within five months. However there is little data regarding the effect of ERT on the outcomes of hip arthroplasty.

From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment.

Objectives: We aimed to assess the incidence of requirement for shoe raises for a leg length discrepancy (LLD) after total hip replacement (THR). We also assessed the patient satisfaction with, and continued use of shoe raises for symptomatic LLD after THR.

Methods: We searched the orthotics records at our institution to identify all patients who had required a shoe raise for symptomatic LLD after primary unilateral total hip replacement between January 2003 and October 2008. 75 patients were identified. 72 were still alive. In the same period 4270 primary hip replacements were carried out at the institution. A questionnaire was sent out to all living patients. Patient details (including satisfaction) and operative details were recorded. Pre-operative and post-operative radiological measurements of leg length discrepancy (LLD) were performed.

Results: The incidence of requirement of a shoe raise for LLD after THR at our institution was 1.8%. 68% were women. 84% of questionnaires were returned. 31% had stopped using their shoe raise completely. Two-thirds of patients found the raise improved their symptoms of a LLD. Symptoms causing dissatisfaction with the shoe raise included new or worsening back pain, limp, uneven walking, self awareness, need to adjust trouser length, pain in other hip, discomfort while walking, and difficulty buying shoes. Patient overall satisfaction with their THR was poor in the patients who were dissatisfied with the shoe raise, but was good in those who found the raise useful.

Conclusion: About 2% of patients may require a shoe raise for symptomatic LLD after THR. Of these 65% will find the shoe raise helpful. Patient with a LLD after a THR that is not helped by a shoe raise are very dissatisfied. It is important that surgeons should take great care to avoid causing a LLD after THR as it can be a cause of very low patient satisfaction.

Introduction: Leg length discrepancy (LLD) following total hip replacement (THR) is not uncommon. Some patients are symptomatic, with problems such as gait imbalance or back pain. LLD is a potential cause of litigation following THR.

We have observed that some patients perceive their LLD to be much greater than the true LLD. A large LLD is sometimes reported by therapists, despite only a small true LLD.

We have found that abduction tightness is a potent cause of apparent LLD, and report our investigations into this phenomenon.

Method: We have identified a series of patients with abductor tightness and a significant apparent LLD. The LLD becomes apparent when the operated leg is adducted to the midline (or when the patient stands with their ankles together). This causes the contralateral pelvis to elevate and the un-operated leg to “shorten”.

Clinical photographs and videos have been produced to demonstrate this phenomenon.

A 2-dimensional model has been made to demonstrate how the degree of abduction, offset and over-lengthening affect this phenomenon.

A computer model has been used to quantify these effects.

Results: An abduction contracture after THR will cause the un-operated leg to be apparently and functionally short, even in the absence of a true discrepancy.

Even with only minor abductor tightness, increasing the true length will disproportionately increase the apparent LLD.

Conclusion: An abduction contracture is a potent cause of apparent LLD. Even a small degree of true over lengthening will be greatly magnified by this phenomenon. We recommend careful clinical assessment for abductor tightness when examining patients complaining of a LLD after THR.