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Aims: Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants., Methods: A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed., Results: At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint., Conclusion: The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J  2021;103-B(7 Supple B):129-134.

Background: This study was performed to investigate leg length discrepancy (LLD), overgrowth, and associated risk factors after pediatric tibial shaft fractures., Materials and Methods: This study included 103 patients younger than 14 years of age (mean age 7.1 years; 75 boys, 28 girls) with unilateral tibial shaft fracture and a minimum follow-up of 24 months. LLD was calculated as the difference between the lengths of the injured and uninjured limbs. Overgrowth was calculated by adding the fracture site shortening from the LLD. Risk factors were assessed in patients with LLD < 1 cm and ≥ 1 cm and overgrowth < 1 cm and ≥ 1 cm., Results: Casting and titanium elastic nailing (TEN) were performed on 64 and 39 patients, respectively. The mean LLD and overgrowth were 5.6 and 6.4 mm, respectively. There were significant differences in sex (p = 0.018), age (p = 0.041), fibular involvement (p = 0.005), injury mechanism (p = 0.006), and treatment methods (p < 0.001) between patients with LLDs < 1 cm and ≥ 1 cm. There were significant differences in sex (p = 0.029), fibular involvement (p = 0.002), injury mechanism (p = 0.008), and treatment methods (p < 0.001) between patients with overgrowth < 1 cm and ≥ 1 cm. Sex and treatment methods were risk factors associated with LLD ≥ 1 cm and overgrowth ≥ 1 cm following pediatric tibial shaft fracture. The boys had a 7.4-fold higher risk of LLD ≥ 1 cm and 5.4-fold higher risk of overgrowth ≥ 1 cm than the girls. Patients who underwent TEN had a 4.3-fold higher risk of LLD ≥ 1 cm and 4.8-fold higher risk of overgrowth ≥ 1 cm than those treated by casting., Conclusions: Patients undergoing TEN showed greater LLD and overgrowth than those undergoing casting, with boys showing greater LLD and overgrowth than girls. Surgeons should consider the possibility of LLD and overgrowth after pediatric tibial shaft fractures, especially when performing TEN for boys., Level of Evidence: Level III.

Background: This study was done to observe the incidence of Osteo-line on the femur neck and to explore the clinical application of Osteo-line in osteotomy., Methods: Eighty-nine adult femur specimens were selected to observe the incidence of Osteo-line on the femur neck. From August 2015 to January 2019, a total of 278 patients who completed unilateral hip arthroplasty at the Third Hospital of Hebei Medical University were retrospectively included. Patients who accepted osteotomy via Osteo-line on the femur neck were defined as the experimental group (n = 139), and patients who accepted osteotomy via traditional method (The femoral distance 1.5 cm above the trochanter was retained for osteotomy by visual inspection.) were defined as the control group (n = 139). According to the postoperative pelvic X-ray, Photoshop was used to evaluate the leg length discrepancy (LLD) by the CFR-T-LT method., Results: Among the 89 specimens, the incidence of anterior Osteo-line was 75.28%, and the incidence of posterior Osteo-line was 100%. According to the clinical application results, the incidence of anterior Osteo-line on the femur neck was 80%, and the incidence of posterior Osteo-line was 100%. The Osteo-line was clearer than those on the femoral specimens. Twenty-six cases had LLD greater than 1 cm (9.29%), including 2 cases in the experimental group and 24 cases in the control group. The average postoperative LLD in the experimental group (0.19 ± 0.38 mm) was significantly shorter than in the control group (0.54 ± 0.51 mm)(P = 0.005)., Conclusion: The incidence of Osteo-line on the femur neck was high, and patients who accepted osteotomy via Osteo-line on the femur neck can achieve shorter postoperative LLD than the control group.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Background and purpose - Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf.Patients and methods - We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims.Results - We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed.Interpretation - The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.

Background: Total hip arthroplasty (THA) is considered a successful surgical procedure. It can be performed by several surgical approaches. Although the posterior and anterolateral approaches are the most common, there has been increased interest in the direct anterior approach. The goal of the present study is to compare postoperative leg length discrepancy and acetabular cup orientation among patients who underwent total hip arthroplasty through a direct anterior (DAA) and anterolateral (ALA) approaches., Methods: The study included 172 patients undergoing an elective THA by a single surgeon at our institution within the study period. Ninety-eight arthroplasties were performed through the ALA and 74 arthroplasties through the DAA. Preoperative planning was performed for all patients. Assessment of the two groups included the following postoperative parameters: abduction angle, cup anteversion angle and leg length discrepancy (LLD). Additional analysis was done to evaluate component positioning by comparing deviation from the Lewinnek zone of safety in both approaches., Results: For the DAA the absolute LLD was 11 mm, ranging from -6 mm to 5 mm. For the ALA, the absolute LLD was 36 mm, ranging from -22 mm to 14 mm. None of the DAA patients had an absolute LLD greater than 6 mm. Comparatively, 7.4% of the ALA group exceeded 6 mm of LLD in addition to 2.1% with LLD greater than 10 mm. 15% of the ALA group resided out of the Lewinnek abduction zone compared to 3% of the DAA group (P = 0.016). 17% of the ALA group were out of the Lewinnek anteversion zone as opposed to 8% of the DAA group (P = 0.094)., Conclusion: Our study demonstrates good component positioning outcomes and LLD values in patients following THA through the DAA compared to the ALA.

Aims: The aims of this study were to examine the rate at which the positioning of the acetabular component, leg length discrepancy and femoral offset are outside an acceptable range in total hip arthroplasties (THAs) which either do or do not involve the use of intra-operative digital imaging., Patients and Methods: A retrospective case-control study was undertaken with 50 patients before and 50 patients after the integration of an intra-operative digital imaging system in THA. The demographics of the two groups were comparable for body mass index, age, laterality and the indication for surgery. The digital imaging group had more men than the group without. Surgical data and radiographic parameters, including the inclination and anteversion of the acetabular component, leg length discrepancy, and the difference in femoral offset compared with the contralateral hip were collected and compared, as well as the incidence of altering the position of a component based on the intra-operative image., Results: Digital imaging took a mean of five minutes (2.3 to 14.6) to perform. Intra-operative changes with the use of digital imaging were made for 43 patients (86%), most commonly to adjust leg length and femoral offset. There was a decrease in the incidence of outliers when using intra-operative imaging compared with not using it in regard to leg length discrepancy (20% versus 52%, p = 0.001) and femoral offset inequality (18% versus 44%, p = 0.004). There was also a difference in the incidence of outliers in acetabular inclination (0% versus 7%, p = 0.023) and version (0% versus 4%, p = 0.114) compared with historical results of a high-volume surgeon at the same centre., Conclusion: The use of intra-operative digital imaging in THA improves the accuracy of the positioning of the components at THA without adding a substantial amount of time to the operation. Cite this article: Bone Joint J 2018;100B(1 Supple A):36-43., (©2018 The British Editorial Society of Bone & Joint Surgery.)

Objective: To assess the incidence of proximal femoral shortening (PFS) and its effect on the patient outcomes when intertrochanteric fractures were treated with a cephalomedullary nail (CMN)., Design: Retrospective cohort study., Settings: Level II trauma center., Patients: Forty-eight consecutive patients with OTA/AO 31-A intertrochanteric fractures., Intervention: All patients were treated with a Gamma3 CMN (Stryker, Kalamazoo, MI)., Methods: PFS was assessed for abductor lever arm (x vector), femoral height (y vector), and overall shortening (z vector) on anteroposterior radiographs. Fixation success and retained ambulatory capacity were noted., Results: Shortening of >5 mm of the x, y, and z vectors was evident in 18, 20, and 29 patients, respectively. Shortening of >10 mm of the x, y, and z vectors was measured in 5, 6, and 8 patients, respectively. Mean shortening of the x, y, and z vectors was 4.5, 5.5, and 7 mm, respectively. Greater PFS was found to be associated with fixation failure and inability to retain ambulatory capacity, independently (P ≤ 0.05 and P ≤ 0.025, respectively). Of note, an unstable fracture pattern was not found to be associated with greater PFS., Conclusions: PFS is a common phenomenon after CMN of intertrochanteric fractures with a Gamma CMN. In addition, greater PFS seems to be associated with fixation failure and inability to retain ambulatory capacity postoperatively., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA)., Patients and Methods: The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed., Results: There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation., Conclusion: IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Perception of a leg length discrepancy post total hip arthroplasty (THA) is one of the most common sources of patient dissatisfaction and can have a direct influence on the considered success of the operation.This research examined postoperative perception of imposed limb discrepancies in a group of THA patients compared to a group of participants with no previous hip surgery. Two subgroups of THA patients were involved: those who did not perceive a difference in limb length following THA and those that did.Discrepancies were imposed in 2.5 mm increments. For discrepancies ≥5 mm, a significant number of participants were aware of a difference (74%). There was no significant difference in perception of imposed discrepancies between THA patients and participants with no previous hip surgery. THA patients who perceived a difference in their limb lengths postoperatively had significantly worse pain and oxford scores when compared to THA patients who perceived their limb lengths to be equal. Knowing the boundaries between LLDs that go undetected and those that patients are aware of could guide surgeons when evaluating the balance between correct soft tissue tension and the resulting unequal leg length. From these findings, discrepancies >5 mm are likely to be perceived. Whether this perception would lead directly to a negative outcome score and patient dissatisfaction is more complex to project and likely to be patient specific. Intraoperative methods to aid the controlled positioning of implanted components could help maintain and restore leg length to within an acceptable amount that patients cannot perceive.

Objectives: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening., Design: Retrospective chart review., Setting: Level I trauma centre., Patients/participants: Sixty-five patients with a median age of 51 years (interquartile range: 42-56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws., Intervention: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw., Main Outcome Measurements: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation., Results: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03)., Conclusions: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

This study assesses femoral neck shortening and its effect on gait pattern and muscle strength in patients with femoral neck fractures treated with internal fixation. Seventy-six patients from a multicenter randomized controlled trial participated. Patient characteristics and Short Form 12 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected. Femoral neck shortening, gait parameters, and maximum isometric forces of the hip muscles were measured and differences between the fractured and contralateral leg were calculated. Variables of patients with little or no shortening, moderate shortening, and severe shortening were compared using univariate and multivariate analyses. Median femoral neck shortening was 1.1 cm. Subtle changes in gait pattern, reduced gait velocity, and reduced abductor muscle strength were observed. Age, weight, and Pauwels classification were risk factors for femoral neck shortening. Femoral neck shortening decreased gait velocity and seemed to impair gait symmetry and physical functioning. In conclusion, internal fixation of femoral neck fractures results in permanent physical limitations. The relatively young and healthy patients in our study seem capable of compensating. Attention should be paid to femoral neck shortening and proper correction with a heel lift, as inadequate correction may cause physical complaints and influence outcome., (Copyright 2013, SLACK Incorporated.)

The purpose of this study was to evaluate the effectiveness and complication rate of guided growth for the treatment of patients with a moderate leg-length discrepancy. The authors retrospectively reviewed all patients treated with guided growth for a moderate leg-length discrepancy at their institution between October 2004 and December 2010. Thirty-four patients met the inclusion criteria from an initial cohort of 105 patients. All patients were followed until screw removal or maturity occurred. Nine patients had a developmental leg-length discrepancy, and 25 had a congenital leg-length discrepancy. Average age was 12.6 years (range, 7-16 years). Average leg-length discrepancies, as measured on standing long-leg radiographs from the top of the pelvis, the top of the femoral heads, and the center of the ankle to the top of the femoral heads, were 22, 19, and 17 mm, respectively. Average discrepancies at screw removal or maturity were 13, 10, and 11 mm, respectively. Twenty of 33 patients had a leg-length discrepancy of less than 1 cm at maturity or screw removal. The leg-length discrepancy change in patients who underwent guided growth of the tibia was minimal. Leg-length discrepancies in patients who underwent guided growth of the femur or both the femur and the tibia changed by an average of 10 mm. One patient had a mechanical axis change greater than 1 zone, and 1 patient required treatment for angular deformity after being treated for a leg-length discrepancy. Guided growth is a safe and effective technique for treating moderate leg-length discrepancies., (Copyright 2013, SLACK Incorporated.)

Limb-length discrepancy following total hip arthroplasty (THA) is often cited as a reason for patient dissatisfaction and for hip instability. Various intraoperative techniques have been described to help restore normal limb length after THA. The purpose of this study was to assess whether a computer-navigated surgical technique would help restore limb-length equality following THA.A retrospective study of 150 consecutive patients compared a free-hand (non-navigated) THA technique vs a computer-navigated THA technique. Each group contained 75 patients. The primary outcome measurement was limb-length discrepancy, which was evaluated using a digital anteroposterior pelvic radiograph. Secondary outcome measurements included a Harris Hip Score questionnaire and a single question evaluating the subjective feeling of the operative limb (longer, shorter, or equal). At a minimum 1-year follow-up, results showed that computer-navigated THA helped restore limb-length equality. An average leg-length difference of 0.3 mm (SD=0.3 mm) was found with computer-navigated THA compared with a leg-length difference of 1.8 mm (SD=0.7 mm) when a non-navigated THA was used. This was statistically significant. Both groups had similar Harris Hip Scores (computer-navigated group, 84.8; non-navigated group, 84.2; P=.835), and no difference was found between the 2 groups regarding the patient's perception of the operative limb length.This study demonstrated that computer-navigated THA resulted in improved restoration of normal limb length and limited significant outliers but did not show improvement in Harris Hip Scores or patient's perception of limb-length equality., (Copyright 2013, SLACK Incorporated.)