Correction Of Leg Length Discrepancy Research Articles

Simultaneous correction of leg length discrepancy and angular deformity of the distal femur with retrograde Precice nails: a retrospective analysis of 45 patients.

Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment? Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment. The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication. Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.

Total Hip Arthroplasty in Patients Who Have Crowe Type IV Developmental Dysplasia of the Hip: A Systematic Review

BackgroundDevelopmental dysplasia of the hip (DDH) is one of the principal causes of secondary hip osteoarthritis, giving rise to considerable pain, impaired mobility, and a reduced quality of life. The optimal approach to managing individuals who have Crowe type IV DDH remains controversial. This study aimed to review the existing literature on the application of total hip arthroplasty (THA) as a treatment modality for Crowe type IV DDH, assessing its efficacy in addressing this severe hip deformity. MethodsA comprehensive search across the PubMed, Scopus, and Web of Science databases identified relevant studies. Inclusion criteria encompassed investigations reporting outcomes of THA in Crowe type IV DDH patients. Data extraction and quality assessment were performed independently by 2 reviewers. Utilizing R software, the prevalence of THA complications was analyzed through proportion analysis, employing the inverse variance method. ResultsIn this systematic review, a total of 74 studies were included, comprising a collective sample size of 2,829 patients (3,356 hips) diagnosed with Crowe type IV DDH. The posterior or posterolateral approach was the most commonly utilized surgical approach, followed by the lateral Hardinge and direct lateral approaches. The majority of studies have employed subtrochanteric osteotomies. Notably, post-THA, leg length discrepancy decreased, Trendelenburg sign resolved, and back pain was reduced. Patient-reported outcome measures like the Harris Hip Score improved significantly. The pooled prevalence rates of major postoperative complications were also assessed, including dislocation (7.2%), revision (8.7%), intraoperative fractures (10.5%), loosening (5.7%), nerve paralysis (5.6%), deep vein thrombosis (3.6%), infection (3.8%), heterotopic ossification grade 2 and above (6.1%), and a complicated patient rate of 11.0%. ConclusionsSynthesizing diverse study data, an overview of THAs performance emerges, demonstrating significant enhancements in function, pain reduction, quality of life, and the correction of substantial leg length discrepancy. While THA has shown positive outcomes, instances of complications have been reported. The decision to undergo THA should involve a collaborative assessment between the surgeon and the patient, considering potential benefits and complications.

An innovative staged prosthetic lengthening reconstruction strategy for osteosarcoma-related leg discrepancy

Correction of leg length discrepancy (LLD) in skeletally mature patients with osteosarcoma was rarely reported and quite challenging. This study aimed to propose a treatment strategy of staged lengthening and reconstruction with a standard static prosthesis to address LLD and restore limb function. It also evaluated the effectiveness of the strategy in terms of leg lengthening, functional outcomes, and complications. The strategy for lengthening included three stages. In stage 1, the previous prosthesis was removed and an external fixator with a temporary rod-cement spacer was placed. In this stage, the external fixator was used to lengthen the limb to the appropriate length. In stage 2, the external fixator was removed and the old rod-cement spacer was replaced with a new one. In stage 3, the rod-cement spacer was removed and the standard static prosthesis was planted. Nine skeletally mature distal femoral osteosarcoma patients with unacceptable LLD were treated in our institution from 2019 to 2021. We performed a chart review on nine patients for the clinical and radiographic assessment of functional outcomes, LLD, and complications. The mean (range) leg lengthening was 7.3 cm (3.6–15.6). The mean (range) LLD of the lower limbs decreased from 7.6 cm (4.1–14.2) before the lengthening to 0.3 cm (− 0.3 to 2.1) at the final follow-up with statistical significance (P = 0.000). The mean (range) Musculoskeletal Tumor Society score improved from 30.3% (16.7%–53.3%) before the lengthening to 96.3% (86.7%–100%) at the final follow-up with statistical significance (P = 0.000). Three patients (33.3%) had a minor complication; none needed additional surgical intervention. In the short term, the current staged lengthening and reconstruction with standard static prosthesis provided satisfactory functional outcomes and LLD correction with few complications. The long-term effects of this method need further exploration.

Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years.

Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy. (1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches? We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database. At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups. In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies. Level III, therapeutic study.

Stricter correction of leg length discrepancy is required during total hip arthroplasty in patients with ankylosing spondylitis

BackgroundPatients with ankylosing spondylitis often have fusions in the spine and sacroiliac joints, such that it is difficult to compensate for leg length discrepancy (LLD).MethodsWe retrospectively measured the LLD after total hip arthroplasty (THA) in 89 patients with ankylosing spondylitis from June 2004 to February 2021 at our institute. Patients were divided into two groups based on an LLD of 5 mm. Clinical outcomes were investigated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Harris Hip Score (HHS). In addition, these points are investigated: patient satisfaction with the operation; whether there was a current difference in leg length; and whether there was a limping gait.ResultsThe group with an LLD of 5–10 mm rather than < 5 mm had significantly worse WOMAC pain and stiffness. The survey revealed statistically significant differences in patient satisfaction with the operation, limping gait, and whether back pain had improved.ConclusionFor patients with ankylosing spondylitis, reducing the LLD to < 5 mm, which is more accurate than the current standard of < 10 mm, may produce greater improvement in clinical outcomes after hip arthroplasty.

Antegrade Intramedullary Femoral Lengthening and Distal Temporary Hemiepiphysiodesis for Combined Correction of Leg Length Discrepancy and Coronal Angular Deformity in Skeletally Immature Patients.

Leg length discrepancies (LLD) are frequently associated with coronal malalignment. Temporary hemiepiphysiodesis (HED) is a well-established procedure for the correction of limb malalignment in skeletally immature patients. For treatment of LLD > 2 cm, lengthening with intramedullary devices gains increasing popularity. However, no studies have investigated the combined application of HED and intramedullary lengthening in skeletally immature patients. This retrospective single-center study evaluated the clinical and radiological outcomes of femoral lengthening with an antegrade intramedullary lengthening nail combined with temporary HED performed in 25 patients (14 females) between 2014 and 2019. Temporary HED through the implantation of flexible staples of the distal femur and/or proximal tibia was either performed prior (n = 11), simultaneously (n = 10) or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). The median initial LLD was 39.0 mm (35.0-45.0). Twenty-one patients (84%) presented valgus and four (16%) showed varus malalignment. Leg length equalization was achieved in 13 of the skeletally mature patients (62%). The median LLD of the eight patients with residual LLD > 10 mm at skeletal maturity was 15.5 mm (12.8-21.8). Limb realignment was observed in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Combining antegrade femoral lengthening and temporary HED is a viable option to correct LLD and coronal limb malalignment in skeletally immature patients; however, achieving limb length equalization and realignment may be difficult in cases of severe LLD and angular deformity, in particular.

Influence of a shoe lift for correction of leg length discrepancy in children with spastic unilateral cp

Influence of a shoe lift for correction of leg length discrepancy in children with spastic unilateral cp

Effect of correction of leg length discrepancy on the biomechanical characteristics of the pelvis and hip joints among standing workers.

Few studies have reported the contribution of correction of leg length discrepancy (LLD) on the kinematic and kinetic characteristics of the pelvis and hip joints among those who must stand while working using shoe insoles and a three-dimensional (3D) motion analysis system. To investigate dynamic pelvic and hip joint angles and hip moments using a 3D motion analysis system with and without insoles in standing workers with LLD. Kinematic and kinetic data of 31 participants with LLD were collected using a motion analysis system and force platforms. Participants were asked to walk wearing standard shoes or shoes with LLD-corrected insoles. Repeated-measures analysis of variance (ANOVA) was used to compare the kinematic and kinetic data of the hip joints and pelvic orientation according to leg side and corrective interventions for LLD. There were significant differences in maximal ROM of hip adduction and abduction with vs. without LLD insoles in the longer and shorter legs (p < 0.05). There were significant differences in maximal elevation (p = 0.004) and total coronal motion (p = 0.006) of the pelvic segment with and without insole corrections in the longer leg during gait. LLD correction using a customized insole is a recommended therapeutic intervention to improve the musculoskeletal imbalances of hip and pelvic segments in workers with LLD.

Epiphysiodesis and hemiepiphysiodesis : Physeal arrest and guided growth for the lower extremity

Durch das Prinzip der Wachstumsblockade mittels Epiphysiodese und der Wachstumslenkung durch Hemiepiphysiodese können sowohl Beinlängendifferenzen als auch sagittale, koronare und schräge Achsdeformitäten an der unteren Extremität während des Wachstums korrigiert werden. Es werden temporäre und permanente Techniken unterschieden. Der große Vorteil liegt in der minimal-invasiven Anwendung und den geringen Komplikationen. Essenziell sind die genaue Planung sowie das exakte Timing, besonders wenn permanente Verfahren angewandt werden. Die Anwendung rund um das kindliche Kniegelenk kann als Goldstandard der Behandlung von Beinlängendifferenzen und Varus- und Valguskorrekturen bezeichnet werden. Die Wachstumslenkung an der unteren Extremität hat über die letzten Jahre viele neue Einsatzmöglichkeiten an der Hüfte und am Sprunggelenk gefunden. Die erfolgreichen klinischen Ergebnisse mit geringen Komplikationen unterstützen die breite Anwendung der Hemiepiphysiodese und Epiphysiodese am wachsenden Skelett bei Achsfehlstellungen und Beinlängendifferenzen.

Pre-Operative Digital Templating Aids Restoration of Leg-Length Discrepancy and Femoral Offset in Patients Undergoing Total Hip Arthroplasty for Primary Osteoarthritis.

BackgroundPre-operative planning and templating is a crucial pre-requisite for total hip arthroplasty (THA). Recently, the use of digital radiography has allowed templating to be digitalised instead of traditional methods involving the use of radiograph transparencies. The primary aim of this study was to compare the accuracy in correction of leg length discrepancy (LLD) and restoring femoral offset in patients undergoing THA for primary osteoarthritis with pre-operative digital templating (PDT) versus conventionalplanning without digital templating.MethodsThis retrospective cohort study compared two groups of patients who underwent THA for primary osteoarthritis. During the period of the year 2020, 56 patients underwent THA with pre-operative digital templating and 50 patients without digital templating. Two independent blinded observers recorded all radiological data.ResultsThe digital templated and non-digital templated cohorts were matched for variables including age (mean = 71.8 years vs 70.9 years), pre-operative LLD (-4.9mm vs -5.2mm) and pre-operative offset (41.2mm vs 43.7mm). PDT resulted in correction of LLD to <5mm compared to the contralateral hip in 76.8% of cases, 5-10mm in 21.4% and >10mm in one case (1.8%). The non-digital templated cohort had a LLD of <5mm in 50% of cases, 5-10mm in 28% and >10mm in 22%. Chi-square testing demonstrated these results to be statistically significant (p = 0.002). The mean pre-operative offset in the digital templated group was 40mm and 46mm post-operatively. The non-digital templated cohort had a mean pre-operative offset of 42mm and 36mm post-operatively. Independent t-testing revealed statistical significance of these results (p = 0.05).ConclusionPDT leads to an increased likelihood of restoring LLD to <5mm and a significantly increased likelihood of preventing lengthening >10mm. PDT also significantly increases the chance of restoring femoral offset to match the pre-operative native hip. Decreased offset is seen predominantly in the non-digitally templated patients.

Leg Length Discrepancy and Nonspecific Low Back Pain: 3-D Stereophotogrammetric Quantitative Posture Evaluation Confirms Positive Effects of Customized Heel-Lift Orthotics.

Background: The literature reports evidence of leg length discrepancy (LLD) associated with musculoskeletal disorders, alterations in spinopelvic alignment, and body posture, leading to low back pain and lumbar scoliosis. The most common conservative treatment for LLD is the use of internal or external shoe lifts although no treatment guidelines have been established. Aim: The study aimed to contribute to low back pain–LLD relationship comprehension, highlighting the benefits of LLD correction in the nonspecific low back pain (NSLBP) population. Methods: A cross-sectional observational study recruited a cohort of 80 NSLBP patients (48 females, 32 males) with LLD, age (μ = 35 ± 17.2). Entire body posture, including 3-D spine shape reconstruction, was measured using a nonionizing 3-D optoelectronic stereophotogrammetric approach. After the first 3-D posture evaluation, patients were provided with customized orthotics, including 100% LLD heel lift correction. No other therapeutic interventions were considered. Pain level was assessed using the numerical pain rating scale (NPRS). The gender, age-related, and time-dependent effects of LLD equalization treatment in NSLBP patients was investigated during 2 years of follow-up. The statistical analysis was performed at the global level using multivariate methods by Hotelling T 2 tests and intrasubject-level using t-test. Results and Discussion: An initial average NPRS = 7.8 was determined. In the medium-term follow-up group (4 months), the NPRS dramatically decreased (NPRS = 1.1). The pain disappeared in the long-term (2 years) follow-up group (NPRS = 0). The study results highlight that LLD equalization treatment led to clear statistically significant improvements in all the postural parameters of the frontal plane, including the underfoot load asymmetry. No worsening has been detected. An adaptation period long enough is needed to obtain progressive pain relief improvements and structural posture changes. Younger NSLBP patients showed slightly better improvements than older ones. Minimal differences between healthy young adults’ and NSLBP patients’ postures were found either in natural erect standing posture or when LLD equalization is applied. Conclusion: Heel-lift customized orthotics with 100% LLD correction are an effective short- and long-term treatment in patients with nonspecific LBP, inducing pain symptom recession and stimulating the improvement of postural parameters without contraindications.

Acute Femoral Lengthening in Adults Using Step-Cut Osteotomy, Traction Table, and Proximal Femoral Locking Plate Fixation: Surgical Technique and Report of Three Cases.

Leg-length discrepancy (LLD) can cause distinct gait and posture disorders that may lead to lifestyle-limiting disability and premature joint degeneration. The purpose of this study was to describe a novel surgical method for acute femoral lengthening in adults with symptomatic structural LLD using step-cut osteotomy, traction table, and proximal femoral locking plate fixation. We retrospectively evaluated three consecutive adult patients that underwent the procedure at our institution between 2011 and 2019, describing the surgical technique and presenting a report of three cases, including complications assessment. The average age was 47years (range 38-58), average BMI was 28.1kg/m2 (range 26.8-29.9), average ASA score was 2 (range 1-3). The mean pre-operative shortening (2 congenital, 1 posttraumatic) was 21mm (range 20-23). The average elongation achieved was 18mm (range 15-20). The average surgery duration was 142min (range 120-165) and the average estimated blood loss was 558mL (range 375-900). Symptoms were relieved after the lengthening in all three cases. We observed no complications after the mean 68months (range 22-125) of follow-up. Successful correction of structural LLD is challenging, depends on patient selection, meticulous planning, surgical technique and experience. Therefore, it should be considered case-by-case. In the hands of an experienced surgeon, our method of acute femoral lengthening seems safe and suitable for carefully selected cases of structural LLD correction, where the final lengthening goal remains within the critical limits of one-stage leg lengthening and principles of traction table use.

Growth arrest: leg length correction through temporary epiphysiodesis with a novel rigid staple (RigidTack).

Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework. A cohort of 56 patients, including 45 unilateral EDs for LLD and 11 bilateral EDs for tall stature, were prospectively analyzed. ED was performed with 222 rigid staples with a mean follow-up of 24.4 months (8 to 49). Patients with a predicted LLD of ≥ 2 cm at skeletal maturity were included. Mean age at surgery was 12.1 years (8 to 14). Correction and complication rates including implant-associated problems, and secondary deformities as well as perioperative parameters, were recorded (IDEAL stage 2a). These results were compared to historical cohorts treated for correction of LLD with two-hole plates or Blount staples. The mean LLD was reduced from 25.2 mm (15 to 45) before surgery to 9.3 mm (6 to 25) at skeletal maturity. Implant-associated complications occurred in 4/56 treatments (7%), and secondary frontal plane deformities were detected in 5/45 legs (11%) of the LLD cohort. Including tall stature patients, the rate increased to 12/67 legs (18%). Sagittal plane deformities were observed during 1/45 LLD treatments (2%). Compared to two-hole plates and Blount staples, similar correction rates were observed in all devices. Lower rates of frontal and sagittal plane deformities were observed using rigid staples. Treatment of LLD using novel rigid staples appears a feasible and promising strategy. Secondary frontal and sagittal plane deformities remain a potential complication, although the rate seems to be lower in patients treated with rigid staples. Further comparative studies are needed to investigate this issue. Cite this article: Bone Joint J2021;103-B(8):1428-1437.

Comparison of the Effect of Insole Correction on Three-Dimensional Knee Joint Moments during Gait in Standing Workers with Leg Length Discrepancy

Background Few studies have been performed to investigate the correction of leg length discrepancy (LLD) on the kinetic characteristics of the knee joint using a shoe insole during gait among those who must stand while working. Purpose To verify three-dimensional (3D) knee joint moments using a 3D motion capture system and force platforms with and without insoles during gait in standing workers with LLD. Study design This was a repeated-measures design. Methods Twenty-seven standing workers with LLD participated in this study. Kinetic data of the knee joint were collected using a motion analysis system and two force platforms. The participants were asked to walk freely along a 6-m walkway wearing a standard pair of shoes or standard shoes with an LLD-corrected insole. Repeated-measures analysis of variance (ANOVA) was used to compare the knee joint moments according to shoe conditions and limb sides. Results There were significant differences in most moment variables related to the knee joint in participants with LLD-corrected insoles worn on the short limb except for the knee moments of adduction, abduction, and internal rotation (<italic>p</italic>&lt;0.05). Significant differences were shown in the maximal moment of knee adduction, abduction, internal rotation, and external rotation between the long and short legs when the participants wore standard shoes only during gait (<italic>p</italic>&lt;0.05). Conclusions The results demonstrated a significant association between the imbalance of the knee moments and LLD among retail staff who must stand while working. Therefore, the results of this study will be useful in explaining the incidence and biomechanical characteristics of knee osteoarthritis in standing workers with LLD.

Temporary Proximal Tibial Epiphysiodesis for Correction of Leg Length Discrepancy in Children—Should Proximal Fibular Epiphysiodesis Be Performed Concomitantly?

The need for concomitant proximal fibular epiphysiodesis (PFE) when correcting leg length discrepancy (LLD) with temporary proximal tibial epiphysiodesis (PTE) in children is controversially discussed. This single center, retrospective cohort study analyzes proximal fibular growth in patients treated by PTE with and without concomitant PFE. Radiographic measurements were conducted before implantation and at implant removal. The position of the fibular head in relation to the tibia was assessed with recently established radiographic reference values. All patients (n = 58, 19 females) received PTE to treat LLD at a mean age of 12.2 years (range 7 to 15). In 27/58 (47%) concomitant PFE was performed. Mean follow-up was 36.2 months (range 14.2 to 78.0). The position of the proximal fibula at implant removal was within physiological range in 21/26 patients (81%) with PFE and in 21/30 patients (70%) without PFE. Proximal fibular overgrowth newly developed in 2/26 patients (8%) treated with PFE and in 5/30 patients (17%) treated without PFE (p = 0.431). Peroneal nerve injury or discomfort due to proximal fibular overlength was not reported. The position of the proximal fibula should be critically assessed preoperatively under consideration of reference values before PTE. In consequence of this study, the authors do not routinely perform PFE concomitantly with PTE for correction of moderate LLD in children if the proximal fibula is localized within physiological radiographic margins determined by the established reference values.

False-negative joint aspiration of septic arthritis of the hip in neonates.

In neonates, timely detection of septic arthritis of the hip can be challenging. Joint aspiration can be a useful diagnostic procedure, but scanty fluid in a septic joint has been reported, leading false-negative results. This study aimed to investigate clinical course of neonates with septic arthritis of the hip despite initial negative findings on joint aspiration. The neonates who surgically treated for septic arthritis of the hip between 2003 and 2013 for septic arthritis of the hip despite initial negative joint aspiration were retrospectively reviewed. Clinical presentations, MRI, intraoperative findings, functional and radiographic outcomes were evaluated. Six neonates were included with a mean follow-up of 12 years (range 5-15 years). All patients showed negative results on joint aspirations performed with ultrasound guidance or fluoroscopy. The mean duration between the onset of symptoms and initial surgery was 15.2 days (range 4-25 days). Four patients (67%) had extracapsular abscesses that were connected to perforated joint capsules on MRI. Intraoperatively, all patients were found to have hip joint instability with a ruptured capsule. Five (83%) patients experienced a complicated recovery. Four patients required reconstructive hip surgery, or further procedures to correct leg length discrepancy. Neonates with false-negative aspiration typically had a delay in appropriate surgical treatment. These cases suggest that the absence of aspirable fluid contents in the hip joint does not rule out septic arthritis in neonates. Our findings highlight the importance of considering spontaneous hip joint capsular perforation as the cause of extra-articular drainage of pus and instability.

The Use of Robotic-Assisted Total Hip Arthroplasty in Developmental Dysplasia of the Hip.

BackgroundTotal hip arthroplasty (THA) is an effective operation for patients with hip osteoarthritis; however, patients with hip dysplasia present a particular challenge. Our novel study examined the effect of robot-assisted THA in patients with hip dysplasia.MethodsWe retrospectively reviewed patients with developmental dysplasia of the hip undergoing primary THA using robotic arm assistance at 2 institutions from January 2010 to January 2017. Patients undergoing revision arthroplasty were excluded. Preoperatively, all patients underwent a computed tomography scan so that 3-dimensional templating could be performed. Hip range of motion (ROM) and clinical leg length discrepancy were recorded preoperatively. Two independent observers calculated Crowe and Hartofilakidis grades for each operative hip. At the final follow-up, hip ROM, postoperative complications, and modified Harris Hip scores were obtained.ResultsSeventy-nine patients underwent THA because of degenerative joint disease in the setting of developmental dysplasia of the hip. There were 56 females and 23 males with a mean age of 45 years (range: 26-64 years). We found that components were placed according to the preoperative plan, that there was an improvement in the modified Harris hip score from 29 to 86 (P < .001), an improvement in the hip ROM (flexion improvement from 66° to 91°, P < .0001), and a correction of leg length discrepancy (17.1 vs 4 mm, P < .0002). There were no complications during the short-term interim follow-up (mean: 3.1 years).ConclusionsRobot-assisted THA can be a useful method to ensure adequate component positioning and excellent outcomes in patients with hip dysplasia.Level of EvidenceLevel III, Retrospective

Patient-reported outcomes following primary total hip arthroplasty in Crowe type III or IV developmental dysplasia are comparable to those in Crowe type I: a case-control study of 96 hips with intermediate-term follow-up

BackgroundA few previous studies have investigated patient satisfaction after total hip arthroplasty (THA) according to the degree of pelvic deformity. This study compared patient-reported outcomes after primary THA for Crowe types III, IV and I dysplasia.MethodsThis retrospective, single-center, single-surgeon case-control study included patients who underwent primary THA between 2008 and 2016. We sent postal questionnaires to 38 patients with Crowe type III and IV dysplasia. Among the questionnaire respondents, 23 patients, excluding those with a follow-up period of < 1 year, were enrolled as the H group. The control group included 46 patients with Crowe type I, matched for sex, age, body mass index and surgical approach. To investigate the influence of femoral shortening osteotomy, the H group was divided according to whether femoral shortening osteotomy was performed. Ten patients underwent THA with femoral shortening osteotomy (FO group), while 12 patients underwent THA without femoral shortening osteotomy (N-FO group). Patient demographics, mean follow-up period, surgical information, pre- and postoperative leg length discrepancy (LLD), and perioperative complications were investigated. Clinical evaluations were performed using the Japanese Orthopaedic Association (JOA) scores, 36-item short-form survey (SF-36), net promotor score (NPS), visual analogue scale (VAS), and questionnaires. The VAS and SF-36 scores were determined only at final follow-up.ResultsThe H and control groups were not significantly different in the postoperative JOA scores and SF-36. In the H group, VAS at the final follow-up was significantly higher, and significantly more patients felt that postoperative rehabilitation was serious, expressing that they underwent THA for LLD correction. In addition, the VAS scores in the FO group was higher than those in the N-FO group. Postoperative LLD was significantly greater in the H group than in the control group. Each group had an NPS of > 50.ConclusionThe postoperative VAS score was higher in Crowe type III and IV dysplasia than in Crowe type I dysplasia, but no significant differences were detected in the postoperative satisfaction, JOA score, and SF-36 score. These findings may help explain the effects of THA preoperatively to patients with Crowe type III and IV dysplasia.Level of evidenceTherapeutic Level 3b.

A new standard radiographic reference for proximal fibular height in children

Background and purpose — To date there is a lack of studies defining the anatomical position of the proximal fibula. This is especially relevant when planning surgical interventions affecting the knee joint such as permanent or temporary epiphysiodesis to correct leg length discrepancies or angular deformities in growing patients. The goal of this study is to establish a standardized measurement technique and radiological reference values for the position of the proximal fibula in children.Patients and methods — 500 measurements were performed in calibrated long standing anteroposterior radiographs of 256 skeletally immature patients (8–16 years; 233 female, 267 male legs). As a radiographic reference in the frontal plane, the distance between the center of the proximal tibial growth plate and a line tangential to the tip of the fibular head and horizontal to the imaging plane was measured (dPTFH).Results — The average value of dPTFH in the studied population (median age 12 years) was –2.7 mm (SD 3, CI –3.0 to –2.5) and normally distributed (p = 0.1). There were no clinically significant sex or age-dependent differences. The inter-rater reliability analysis showed excellent ICC values (ICC = 0.88; CI 0.77–0.93).Interpretation — This study provides a new radiographic reference value to assess the position of the proximal fibula in relation to the proximal tibia in children and adolescents. This reference can aid preoperative decision-making as to whether additional fibular epiphysiodesis is necessary when performing tibial epiphysiodesis to correct moderate leg-length discrepancies.

Indications of sole lift and foot orthoses in the management of mild idiopathic scoliosis-a review.

[Purpose] Leg length discrepancy is common among patients with scoliosis. Some studies reported reduced functional scoliosis curves with correction of leg length discrepancy. Others, however, have shown that induced leg length discrepancy has little effects on spinal deformities. Also, small number of studies assessed the use of foot orthoses in patients with faulty foot biomechanics and their impact on idiopathic scoliosis. In this context, a review of the literature is needed to determine the current evidence for the appropriate use of sole lift and foot orthoses in a context of scoliosis. [Methods] A literature review was performed. [Results] It appeared that sole lifts are indicated for functional lumbar scoliosis when the level of the sacrum is parallel to that of the hips. Sole lifts may not be indicated for patients with structural scoliosis, seemingly inducing a compensatory curve. Custom foot orthoses were found to reduce spinal curves in juvenile patients with mild idiopathic scoliosis and concomitant abnormal foot biomechanics. [Conclusion] Sole lift appeared to be indicated in the presence of certain types of functional scoliosis. Custom foot orthoses can be considered in the management of mild idiopathic scoliosis in juvenile patients. Evidence, however, is low and quality studies are needed to validate these findings.