Does the use of intraoperative measurement reduce limb length discrepancies after total hip arthroplasty?

PURPOSE: Postoperative limb length discrepancy (LLD) is a common complication of total hip arthroplasty, and several methods exist to prevent LLD, but each has its benefits and drawbacks. The study investigates the application of intraoperative lower limb length measurement in preventing postoperative LLD. METHODS: This study retrospectively analyzed 70 patients who underwent total hip arthroplasty from October 2018 to July 2022. The length of the lower limb on the operated side was measured intraoperatively using a sterilized paper ruler after the fitting of the trial mould and compared with the healthy side. Then the prosthesis size, depth and neck length were adjusted accordingly. RESULTS: The absolute value of postoperative LLD was found to be 6.68 ± 4.48 mm, of which 53 cases (75.7%) were less than or equal to 10 mm, while 30 patients (42.9%) were less than or equal to 5 mm. CONCLUSION: The use of intraoperative measurement is effective in reducing LLD after total hip arthroplasty.

Does robot-assisted surgery reduce leg length discrepancy in total hip replacement? Robot-assisted posterior approach versus direct anterior approach and manual posterior approach: a propensity score-matching study.

BACKGROUND: Advocates of robot-assisted technique argue that robots could improve leg length restoration in total hip replacement. However, there were few studies to compare the robot-assisted posterior approach (RPA) with conventional posterior approach (PA) THA and direct anterior approach (DAA) THA in LLD. This study aimed to determine whether robot-assisted techniques could significantly reduce LLD compared to manual DAA and manual PA. METHODS: We retrospectively reviewed the cohort of consecutive ONFH patients who underwent THA robot-assisted posterior, manual posterior, and manual DAA from January 2018 to December 2020 in one institution. One experienced surgeon performed all procedures. We calculated the propensity score to match similar patients in different groups by multivariate logistic regression analysis for each patient. We included confounders consisting of age at the time of surgery, sex, body mass index (BMI), and preoperative LLD. Postoperative LLD and Harris hip scores (HHS) at two years after surgery of different cohorts were compared. RESULT: We analyzed 267 ONFH patients treated with RPA, DAA, or PA (73 RPA patients, 99 DAA patients, and 95 PA patients). After propensity score matching, we generated cohorts of 40 patients in DAA and RPA groups. And we found no significant difference in postoperative LLD between RPA and DAA cohorts (4.10 ± 3.50 mm vs 4.60 ± 4.14 mm, p = 0.577) in this study. The HHS at 2 years postoperatively were 87.04 ± 7.06 vs 85.33 ± 8.34 p = 0.202. After propensity score matching, we generated cohorts of 58 patients in manual PA and RPA groups. And there were significant differences in postoperative LLD between the RPA and PA cohorts. (3.98 ± 3.27 mm vs 5.38 ± 3.68 mm, p = 0.031). The HHS at 2 years postoperatively were 89.38 ± 6.81 vs 85.33 ± 8.81 p = 0.019. After propensity score matching, we generated cohorts of 75 patients in manual DAA and PA groups. And there were significant differences in postoperative LLD between the DAA and PA cohorts. (4.03 ± 3.93 mm vs 5.39 ± 3.83 mm, p = 0.031) The HHS at 2 years postoperatively were 89.71 ± 6.18 vs 86.91 ± 7.20 p = 0.012. CONCLUSION: This study found no significant difference in postoperative LLD between RPA and DAA, but we found a significant difference between RPA and manual PA, DAA and manual PA in ONFH patients. We found a significant advantage in leg length restoration in primary total hip arthroplasty with robot-assisted surgery.

Anterolateral approach may be superior to posterolateral approach in controlling postoperative lower limb discrepancy in primary total hip arthroplasty: A single-center, retrospective cohort study.

OBJECTIVES: This study aims to investigate the possible association and comparison between anterolateral approach (ALA) and posterolateral approach (PLA) and postoperative lower limb discrepancy (LLD) in selective total hip arthroplasty (THA). PATIENTS AND METHODS: April 2021 and July 2021, a total of 266 consecutive patients (126 males, 140 females; mean age: 46.7±13.6 years; range, 22 to 60 years) who underwent unilateral primary THA via the ALA or the PLA were retrospectively analyzed. The operations were performed by a single surgical team. All patients were divided into two groups according to the approach: ALA group (n=66) and PLA group (n=200). Relevant data were recorded. Diagnosis including hip osteoarthritis, developmental dysplasia of the hip (DDH), aseptic avascular necrosis (AVN), and inflammatory arthritis were noted. Perioperative follow-up radiographs were evaluated and measured to compare the postoperative LLD and offset. The association between two approaches and postoperative LLD and offset was analyzed using the univariate and multivariate linear regression analysis. RESULTS: The mean follow-up was 20±3.7 (range, 16 to 25) months. Univariate analysis revealed that the postoperative LLD, the postoperative acetabular offset, and hospital costs were lower in the ALA group than the PLA group (p<0.01). However, the offset and length of stay were comparable between the two groups (p>0.05). Multivariate analysis revealed that the PLA (ß=4.71; 95% confidence interval [CI]: 1.78 to 7.64), preoperative LLD (ß=0.29; 95% CI: 0.21 to 0.37), DDH (ß=5.01; 95% CI: 1.47 to 8.55), and AVN (ß=3.81; 95% CI: 0.50 to 7.12) were the main contributors to the postoperative LLD. CONCLUSION: Our study results suggest that the ALA may be superior to the PLA in controlling the postoperative LLD among some of the selective unilateral primary THA patients. Both the ALA and the PLA were comparable in terms of the restoration of offset.

Effectiveness of a patient-specific guide for femoral stem implantation in primary total hip arthroplasty: a randomized control trial.

PURPOSE: The purpose of the present study was to evaluate the efficacy and feasibility of a novel CT-based patient-specific femoral alignment guide (PSG) as compared with conventional pre-operative planning during THA. METHODS: From March 2020 to September 2020, patients receiving unilateral primary THA were enrolled and randomly allocated to the conventional pre-operative planning group and the PSG group. Primary outcomes were radiographic measurements including lower limb length, femoral offset, femoral anteversion and stem varus/valgus angle, and post-operative perception of leg length discrepancy (LLD). Secondary outcomes were surgical time, intra-operative blood loss, total blood loss, visual analogue scale (VAS), and Harris Hip Score (HHS). The occurrence of post-operative complications was also recorded. RESULTS: Of the 104 patients screened, 80 cases were enrolled for analysis. The demographics of the two groups were similar. The PSG group illustrated significant improvements (p < 0.001) in lower limb length, femoral offset, femoral anteversion, and stem varus/valgus angle. Patients in the PSG group showed more favourable HHS (p < 0.001) at seven day, four week, andthree month (p = 0.003) follow-up. Perception of LLD was found significantly lower in the PSG group at three tmonth (p = 0.043), six month (p = 0.025), and 12-month (p = 0.048) follow-up. Utilization of the PSG had no significant increase in operative time, intra-operative blood loss, total blood loss, or VAS. No complication was noted in either group. CONCLUSION: Relative to conventional pre-operative planning, the application with the PSG could potentially provide a simple and reliable solution for improving femoral prosthesis orientation in THA with high accessibility and low healthcare costs. TRN: ChiCTR2000031043 Date of registration: 2020/3/21.

Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails?

INTRODUCTION: Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. DISCUSSION: Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. CONCLUSION: If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.

Total hip arthroplasty through the direct anterior approach with and without the use of a traction table: a matched-control, retrospective, single-surgeon study.

BACKGROUND: Hip surgeons performing total hip arthroplasty (THA) through the direct anterior approach (DAA) commonly use a traction table to facilitate exposure. Even though performing THA through DAA without a traction table could be technically more demanding, this technique offers the advantage of intraoperative leg length comparison. Therefore, this study aimed to compare clinical outcomes, complication rates, component positioning, and leg length discrepancy (LLD) after THA through the DAA performed with or without a traction table. METHODS: A single-surgeon continuous series of 75 patients who underwent DAA THA performed with a traction table was matched for gender, age, and BMI with 75 patients who underwent DAA THA performed without a traction table (male, 62; female, 88, with an average age of 68 years old). Clinical and radiological outcomes, intra- and postoperative complications, and LLD were retrospectively assessed. RESULTS: No statistically significant difference was detected in surgical time, hospital stay, Harris Hip Score (HHS), complication rates, and implant positioning between the two groups. Leg length restoration was significantly more accurate in the group performed without a traction table (2.4 ± 2 mm vs. 3.7 ± 3.1 mm; p value ≤ 0.05). No LLD > 10 mm was reported in the group performed without a traction table, whereas two cases (2.7%) were reported in those performed with a traction table. CONCLUSION: Performing THA through DAA without a traction table was associated with a significantly more accurate leg length restoration without a significant increase in the rates of intra- and postoperative complications.

Ten-year results of 55 dysplasia hips of hip offset and leg length reconstruction in total hip arthroplasty with cementless tapered stems having a high offset option designed for dysplastic femur.

PURPOSE: In developmental dysplasia of the hip (DDH), the centers of hip rotation move in the superior and lateral direction. In total hip arthroplasty for such cases, movement of the center of hip rotation is in the inferior and medial direction. It causes an increase in leg length and a decrease in acetabular offset. We therefore evaluated the change of hip offset and leg length before and after surgery with two stems having a high offset option. PATIENTS AND METHODS: The preoperative diagnosis was secondary osteoarthritis due to DDH excluded Crowe IV. A stem selection was decided based on preoperative two-dimensional templating. Total 55 hips in 50 patients were followed up for minimum 10 years. Pre- and postoperative clinical evaluations were performed using a hip joint function scoring system. Radiographic evaluations were used for offset and leg length measurements and other associated factors. RESULTS: Both stems showed excellent clinical results. A high offset option was used in 60% of all cases. No postoperative dislocations were observed. The biological fixation was stable in all cases. The hip offset was restored without excessive leg lengthening in most cases. CONCLUSION: Anatomical consistency could be maintained by using a stem which matched geometry of the proximal part and had offset option. These cementless tapered stems having a high offset option are suitable for Crowe I to III hip dysplasia if two-dimensional X-ray templates fit the shape of the proximal femurs. They were associated with excellent clinical results and biological fixation. The offset option may be useful to adjust leg length and offset in DDH patients.

A new method for intraoperative assessment of leg length, sizing and placement of the components in total hip replacement.

BACKGROUND: Intraoperative radiograph of the pelvis is a well-established way to avoid misplacement/undersizing of the components and leg length discrepancy (LLD) in total hip replacement (THR). We describe a method for the obtainment and the evaluation of intraoperative radiographs with a sophisticated wireless radiographic system and a computerized digital tool originally used for preoperative templating. METHODS: In this retrospective case-control study, 60 patients with unilateral hip osteoarthritis who underwent THR with intraoperative radiographic check with the conventional method (n = 30, control group) or the new method (AGFA flat panel DR14eG™/Orthosize™, n = 30, case group) were evaluated and compared for operation time, intraoperative changes in size/placement of the components and final radiological outcome (LLD, acetabular inclination and femoral offset) based on postoperative radiographs of the pelvis. RESULTS: Mean operation time was lower in case group (85.3 min vs. 103.3 min, p value < 0.005), as well as mean absolute LLD (1.93 mm vs. 2.94 mm, p value = 0.242). There was a higher percentage of intraoperative changes in the offset of the prostheses' head (70% vs. 40%, p value = 0.018) and a significantly lower percentage of patients with LLD > 5 mm in the case group (0% vs. 27%, p value = 0.002). CONCLUSIONS: This new method for the obtainment and assessment of intraoperative radiographs proved to be fast and assuring for keeping LLD below 5 mm in all patients.

A simple method to minimize leg length discrepancy in hip hemiarthroplasty.

PURPOSE: We developed a simple method to minimize leg length discrepancy (LLD) during hip arthroplasty. The purpose of this study is to evaluate the accuracy of the method. PATIENTS AND METHODS: A total of 47 patients who suffered from unilateral femoral neck fracture and underwent hip hemiarthroplasty between 2015 and 2018 were enrolled in this study. We measured the diameter of the contralateral femoral head (D) and the distance (L) between the center of the femoral head and the top of lesser trochanter in the antero-posterior pelvic X-ray view before the operation, the ratio (R) of D to L was calculated. During the operation, the diameter of the femoral head (d) was measured using a Vernier caliper. Then, the distance should be obtained from the center of the femoral head prosthesis to the lesser trochanter was calculated according to the contralateral ratio R. RESULTS: The mean LLD was 4.4±3.2 mm (-4.0 to 11.1 mm), 80.9% of the patients had LLD <6 mm, 93.6% of the patients with LLD <10 mm, only 6.4% ≥10 mm LLD. CONCLUSION: This method is a simple, cost-effective, fast and accurate way to reduce the postoperative leg length discrepancy.

Distal femoral varus osteotomy: results of the lateral open-wedge technique without bone grafting.

BACKGROUND: The lateral opening wedge distal femoral osteotomy (LOWDFO) to reconstruct knee alignment in patients with genu valgum originating in the distal femur has gained importance within the last years. PURPOSE: To analyze clinical and radiographic outcome of patients treated with LOWDFO with respect to bone healing without grafting and patient age. MATERIAL AND METHODS: Twenty-two consecutive patients with genu valgum corrected with 23 LOWDFOs using a Tomofix-locking plate were retrospectively analyzed (mean age 23.7 years). Clinical evaluation was based on pre- and post-operative KOOS scores. A pre- and post-operative radiographic assessment, including MAD, mLDFA, LLD, bone healing, and patella parameters, was performed. Differences between subgroups (age, bone grafting) were analyzed. RESULTS: The restoration of MAD and mLDFA resulted in significantly improved post-operative KOOS5 scores in younger and older patients (p = 0.001). Bone healing without bone grafting was reliable in all patients. The leg length was significantly increased post-operatively (p = 0.001). The Blackburne-Peel ratio was significantly reduced to more normal values post-operatively (p < 0.001). CONCLUSION: LOWDFO without bone grafting is a reliable procedure representing a promising treatment option particularly in young patients with genu valgum. Besides correction of the MAD, a significant leg length increase and additional patella stability can be expected.

Does fully-threaded Headless Compression Screw provide a length-stable fixation in undisplaced femoral neck fractures?

OBJECTIVE: Femoral neck shortening is a common complication after surgical treatment for intracapsular femoral neck fractures. This study investigated whether fully-threaded Headless Compression Screw (FTHCS) can be a more length-stable implant than partially-threaded cannulated screw (PTCS) in reducing femoral neck shortening. METHODS: A total of 50 patients with undisplaced femoral neck fractures (17 treated by internal fixation with three FTHCS, and 33 treated by three PTCS) from 2011 to 2014 were enrolled in this study. The radiography of the hips and medical records were reviewed for proximal femur geometry and complications. RESULTS: Significant shortening of the femoral neck length until union were noted in both group (FTHCS group: -2.5 mm, p = 0.045; PTCS group: -2.4 mm, p = 0.011). There was no significant difference in the length of femoral neck shortening between groups (p = 0.855). Age was the only significant risk factor for >5 mm of femoral neck shortening (p = 0.041). The femoral neck-shaft angle tended to reduce and become more varus in both groups (FTHCS: -2.7°, SD = 4.5, p = 0.028; PTCS: -5.0°, SD = 8.3, p = 0.002), but the differences between groups were nonsignificant (p = 0.577). The complication rates were similar between FTHCS and PTCS (17.6% and 21.2%, p > 0.999). CONCLUSION: The FTHCSs may be a substitute for PTCSs, but it cannot prevent femoral neck shortening and varus collapse after fracture fixation. Future studies should focus on how to preserve femoral neck length and hip function after femoral neck fractures.

Leg length discrepancy after total hip arthroplasty: Can leg length be satisfactorily controlled via anterior approach without a traction table? Evaluation in 56 patients with EOS 3D.

BACKGROUND: Leg length discrepancy (LLD) occurs in about 25% of cases after total hip arthroplasty (THA) and adversely affects function if greater than 10mm. When using the direct anterior approach (DAA), limb length control is considered easier with a standard operating table than with a traction table. However, this assumption has not been confirmed. More specifically, no studies have used EOS imaging, which is currently the reference for assessing limb length. The objectives of this retrospective study were: (1) to use EOS imaging to determine whether THA via the DAA on a standard table allowed satisfactory limb length control; (2) whether LLD was associated with other parameters such as age, gender, body mass index (BMI), or side; and (3) to compare clinical score values between patients with and without LLD. HYPOTHESIS: The DAA without a traction table allows satisfactory limb length control as assessed using 3D EOS imaging. MATERIAL AND METHODS: This retrospective descriptive study included 56 patients who underwent primary THA via the DAA between March 2013 and June 2014. LLD was measured on pre- and post-operative EOS images, using sterEOS™ 3D software. Age, gender, BMI, and side of THA were collected. The 12-item Short Form score, Harris Hip Score, and Postel-Merle d'Aubigné score were determined to look for radio-clinical correlations. RESULTS: Of the 56 patients, 15 (26.8%) had an LLD >10mm before THA and 12 (21.4%) after THA. Limb length equality was restored in 7 patients with 1 with a shorter and 1 with a longer limb before THA. In 5 patients with equal limb length before THA, the operated limb was lengthened after THA, by a mean of 8.92mm (range, 5.8-10.8mm). Thus, in all, 5/56 (8.9%) patients experienced a detrimental change in limb length due to the surgery. No statistically significant differences were found between patients with and without LLD regarding age, gender, BMI, side, or clinical scores. DISCUSSION: Although the frequency of LLD after THA in our study was consistent with earlier reports, our results show that good limb length control can be obtained via the DAA with a standard operating table. Thus, 7 of the 11 patients with a shorter limb and 1 of 4 with a longer limb before THA had equal limb lengths after THA, and only 8.9% of patients experienced a detrimental increase in limb length after THA. The DAA without a traction table allows satisfactory intra-operative limb length control based on visualisation of anatomical landmarks (antero-superior iliac spines and medial malleoli). This technique is therefore valuable for limiting the risk of LLD. When combined with 3D EOS planning, it may increase the accuracy of limb length adjustment. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Eight-plate epiphysiodesis: are we creating an intra-articular deformity?

Aims: Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates. Patients and Methods: A retrospective study was performed including 42 children at a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion in the proximal tibia for correction of coronal plane deformities or LLD between 2007 and 2015. A total of 64 plates were inserted; 48 plates (34 patients) were inserted to correct angular deformities and 16 plates (8 patients) for LLD. Medical records, Picture Archive and Communication System images, and conventional radiographs were reviewed. Measurements included interscrew angle, lateral and medial plateau slope angles measured between the plateau surface and the line between the ends of the physis, and tibial plateau roof angle defined as 180° minus the sum of both plateau angles. Measurements were compared between radiographs performed adjacent to surgery and those at latest follow-up, and between operated and non-operated plateaus. Statistical analysis was performed using BMDP Statistical Software. Results: Slope angle increased in 31 (49.2%) of operated epiphyses by a mean of 5° (1° to 23°) compared with 29 (31.9%) in non-operated epiphyses (p = 0.043). Roof angle decreased in 29 (46.0%) of operated tibias and in 25 (27.5%) of non-operated ones by a mean of 5° (1° to 18°) (p = 0.028). Slope angle change frequency was similar in patients with LLD, varus and valgus correction (p = 0.37) but roof angle changes were slightly more frequent in LLD (p = 0.059) and correlated with the change in inter screw angles (r = 0.74, p = 0.001). Conclusion: The use of eight-plates in the proximal tibia for deformity correction and limb-length equalization causes a change in the bony morphology of the tibial plateau in a significant number of patients and the effect is more pronounced in the correction of LLD. Cite this article: Bone Joint J 2018;100-B:1112-16.

Comparison of early complications between the use of a cannulated screw locking plate and multiple cancellous screws in the treatment of displaced intracapsular hip fractures in young adults: a randomized controlled clinical trial.

BACKGROUND: The incidence of early postoperative complications of displaced intracapsular hip fractures is high. The purpose of this study was to compare the early postoperative complications and assess the incidence of femoral neck shortening on using a newly designed proximal femoral cannulated screw locking plate (CSLP) versus multiple cancellous screws (MCS) in the treatment of displaced intracapsular hip fractures in young adults. METHODS: Sixty-eight young adult patients with displaced intracapsular hip fractures were randomly assigned to either the CSLP group or the MCS group and treated routinely by internal fixation with either the CSLP or the MCS. Harris Hip Score, nonunion, failure of fixation, overall complications, and femoral neck shortening were recorded and compared. RESULTS: Two patients (5.88%) in the CSLP group and eight (23.53%) in the MCS group had postoperative nonunion (P < 0.05). There was one case (2.94%) of fixation failure in the CSLP group and three cases (8.82%) in the MCS group (P > 0.05). Three patients (8.82%) in the CSLP group and 11 (32.35%) in the MCS group had overall complications (P < 0.05). Mean femoral neck shortening was 5.10 mm in the vertical plane and 5.11 mm in the horizontal plane in the CSLP group and 11.14 mm in the vertical plane and 10.51 mm in the horizontal plane in the MCS group. Severe femoral neck shortening (≥ 10 mm) did not occur in either the vertical or the horizontal plane in any patient of the CSLP group but occurred in 10 patients (28.57%) in the vertical plane and in 8 (22.86%) patients in the horizontal plane in the MCS group. CONCLUSIONS: Compared with MCS, the use of CSLP in the treatment of displaced intracapsular hip fractures in young adults can reduce the rates of postoperative nonunion and overall complications and minimize femoral neck shortening. TRIAL REGISTRATION: ChiCTR1800016032 . Registered 8 May 2018. Retrospectively registered.

Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb-Length Discrepancy Lead to Improved Comfort and Gait.

OBJECTIVE: Patient adherence is a challenge in offloading diabetic foot ulcers (DFUs) with removable cast walkers (RCWs). The size and weight of an RCW, changes to gait, and imposed limb-length discrepancies may all discourage adherence. This study sought to determine whether RCW size and provision of a contralateral limb lift affected users' comfort and gait. RESEARCH DESIGN AND METHODS: Twenty-five individuals at risk for DFUs completed several 20-m walking trials under five footwear conditions: bilateral standardized shoes, a knee-high RCW with shoe with or without an external shoe lift contralaterally, and an ankle-high RCW with shoe with or without an external shoe lift contralaterally. Perceived comfort ratings were assessed through the use of visual analog scales. Spatial and temporal parameters of gait were captured by an instrumented walkway, and plantar pressure was measured and recorded using pedobarographic insoles. RESULTS: The bilateral shoes condition was reported to be most comfortable; both RCW conditions without the lift were significantly less comfortable (P < 0.01). In contrast to the ankle-high RCW, the knee-high RCW resulted in significantly slower walking (5.6%; P < 0.01) but greater offloading in multiple forefoot regions of the offloaded foot (6.8-8.1%; P < 0.01). Use of the contralateral shoe lift resulted in significantly less variability in walking velocity (52.8%; P < 0.01) and reduced stance time for the offloaded foot (2.6%; P = 0.01), but it also reduced offloading in multiple forefoot regions of the offloaded foot (3.7-6.0%; P < 0.01). CONCLUSIONS: Improved comfort and gait were associated with the ankle-high RCW and contralateral limb lift. Providing this combination to patients with active DFUs may increase offloading adherence and subsequently improve healing.

Minimizing Leg Length Discrepancy After Intramedullary Nailing of Comminuted Femoral Shaft Fractures: A Quality Improvement Initiative Using the Scout Computed Tomography Scanogram.

OBJECTIVES: To prevent leg length discrepancy (LLD) after locked femoral nailing in patients with comminuted femoral shaft fractures. DESIGN: Prospective consecutive case series aimed at quality improvement. SETTING: Level 1 Trauma Center PATIENTS:: Ninety-eight consecutive patients with a comminuted femoral shaft fracture underwent statically locked intramedullary nailing, with a focused attempt at minimizing LLD during surgery. INTERVENTION: A computed tomography scanogram of both legs was performed on postoperative day 1 to assess for residual LLD. Patients were offered the option to have LLD >1.5 cm corrected before discharge. MAIN OUTCOME MEASURE: LLD >1.5 cm. RESULTS: Twenty-one patients (21.4%) were found to have an LLD >1.5 cm. An LLD >1.5 cm occurred in 10/55 (18%) antegrade nail patients and 11/43 (26%) retrograde nail patients (P = 0.27). No difference was noted based on the mechanism of injury, surgeon training and OTA/AO type B versus C injury. Ninety of 98 patients left with <1.5 cm LLD, 13/21 had a correction all to ≤0.6 cm, and 8 decided to accept the LLD and declined early correction. CONCLUSIONS: No patient left the hospital with an LLD >1.5 cm after locked intramedullary nailing for a comminuted femoral shaft fracture without being informed and the option of early correction. We recommend using a full-length computed tomography scanogram after IM nailing of comminuted femur fractures to prevent iatrogenic LLD. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intra-operative digital imaging: assuring the alignment of components when undertaking total hip arthroplasty.

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.

[Suitability of computer-assisted femoral intramedullary nailing for control of torsion and length : Systematic review of clinical studies]. / Eignung der computerassistierten Femurmarknagelung zur Kontrolle von Torsion und Länge : Systematischer Literaturüberblick zu klinischen Studien.

BACKGROUND: Despite promising results in experimental studies, computer-assisted femoral intramedullary nailing has not become established in the clinical practice for most orthopedic surgeons. The purpose of this study was to evaluate the advantages and disadvantages of computer-assisted reduction and nailing of femoral fractures as reported in clinical studies. MATERIAL AND METHODS: A systematic analysis of the available literature on the clinical application of computer-assisted femoral intramedullary nailing (Pubmed, Cochrane library and Embase) was carried out. Studies published up to May 2017 were included. RESULTS: A total of three articles were included in this meta-analysis. All studies showed a relevant increase in total operating time and radiation exposure time with the use of computer-assisted femoral intramedullary nailing. The clinical results for computer-assisted nailing with respect to femoral torsion and length tended to be slightly better but the results were very heterogeneous. CONCLUSION: Our analysis could show that computer-assisted femoral intramedullary nailing is clinically feasible but the operative and fluoroscopy time needed are high and the reported postoperative results for femoral length and torsion were very heterogeneous. Further comparative studies are needed in the future.