Leg length discrepancy is not a risk factor for plantar fasciitis.

PURPOSE: Plantar fasciitis (PF) is a main source of heel pain, and only about one-third of patients have bilateral symptomatic involvement, although age, body mass index (BMI), and physical activities are known risk factors. The high prevalence of unilateral involvement is poorly understood. We aimed to assess the potential association between PF and the leg length discrepancy (LLD) in unilateral PF. METHODS: A transversal case-control study was conducted from January 2019 to December 2020, including 120 participants allocated to two groups matched by BMI and sex: cases (with a diagnosis of PF; 50 ± 13 years) and control (without foot pain; 40 ± 15 years). For both groups, a difference greater than 0.64 cm in the scanometry determined the criteria for the presence of LLD. RESULTS: The multivariate logistic regression analysis showed an independent association of PF only with age (p < 0.001), and no association with LLD. We did not observe differences in the mean discrepancy (1.37 ± 0.83 cm in the PF group in comparison with 1.13 ± 0.37 cm in the control group, [p > 0.05]) or in the prevalence of LLD between groups (48% [n = 29] in the PF group compared with 42% [n = 25] in the control group, [p > 0.05]). In the PF group, 80% of the participants reported unilateral pain. We observed a higher prevalence of pain in the shorter limb (p < 0.05). CONCLUSION: Age was the only factor associated with the diagnosis of PF when groups were matched by sex and BMI. LLD was not an independent factor associated with the diagnosis of PF. However, when PF is unilateral, the shorter limb is more affected with 70% of prevalence. LEVEL OF EVIDENCE: Level III, case-control.

Clinically Detected Leg Length Discrepancy in Patients With Idiopathic Clubfoot Deformity: Prevalence and Outcomes.

BACKGROUND: This study evaluates the prevalence and outcomes of patients with idiopathic clubfoot and clinically detected limb length discrepancy (LLD). METHODS: This is a retrospective cohort study of idiopathic clubfoot patients in a Research Ethics Board-approved clubfoot registry. Patients with LLD ≥0.5 cm (LLD+) were compared with those with no or <0.5 cm LLD (LLD-). LLD was determined by documented clinical examination. Exclusion criteria included nonidiopathic clubfoot deformity, <2-year follow-up, and incomplete records. RESULTS: Of the 300 patients included, 27 (9.0%) had an LLD, of whom 23 patients had a unilateral clubfoot deformity. The prevalence of LLD was 15.3% and 2.67% in unilateral and bilateral clubfoot patients, respectively. The mean LLD was 1.21 cm (0.5 to 3.5 cm, SD: 0.78 cm) in LLD+ patients, with a mean of 1.27 cm (SD: 0.79 cm) in unilateral clubfoot patients and 0.88 cm (SD: 0.75 cm) in bilateral patients. The total number of casts applied in LLD+ unilateral clubfoot patients was significantly higher than in LLD- unilateral patients (9.5 vs. 6.8 casts; P =0.015). The overall relapse rate in all patients was 30.3% and was significantly higher in the unilateral only LLD+ group [relative risk (RR)=2.89] and the total LLD+ patient cohort (RR=1.68). The risk of repeat casting for relapse was also higher in the unilateral LLD+ group (RR=2.45) and the total LLD+ group (RR=1.87). The risk of surgery for relapse was significantly higher in the unilateral LLD+ group for any surgery ( P =0.046), and most specifically for open tendo-Achilles tenotomy ( P =0.008) and tibialis anterior tendon transfer ( P =0.019). There was no correlation between the severity of LLD and Pirani score at presentation. CONCLUSIONS: LLD was present in 9% of idiopathic clubfoot patients, and most were <2 cm. There is a significantly higher risk of relapse in patients with unilateral clubfoot and LLD. The risk of surgery overall was higher in all patients with a unilateral LLD. Assessment of LLD should be routinely performed in clubfoot patients. LEVEL OF EVIDENCE: Level III.

Radiologic restoration inaccuracy increases postoperative dislocation in primary total hip arthroplasty: a retrospective study with propensity score matching.

BACKGROUND: Dislocation is a complicated process and associated with multivariate etiology and risk factors. The purpose of this study was to verify if radiologic restoration inaccuracy increases postoperative dislocation in primary total hip arthroplasty (THA) individually or synergistically. METHODS: From 2017 to 2020, we identified 76 (1.9%) patients who suffered postoperative dislocations from 3926 THAs in our institution. After excluded patients with previously proven patient-related and implant-related risk factors, the remaining patients were used to match a 1:1 control patients who were without dislocation. The cup position (inclination and anteversion angles), hip offset (HO), leg length discrepancy (LLD), and abductor lever arm (ALA) were analyzed by univariate analyses and multivariate logistic regressions. RESULTS: Measurements on radiographs showed excellent interobserver agreement (intraclass correlation coefficient (ICC) 0.922-0.952) and intraobserver agreements (ICC 0.933-0.967). HO restoration inaccuracy (without ± 5 mm) was associated with higher dislocation risk (OR 4.241 95% CI 1.440-12.492, P = 0.009). The restoration inaccuracy of the cup position, LLD, or ALA could not increase the dislocation risk individually. When combining the radiologic restoration inaccuracy factors, the HO + LLD restoration inaccuracy and HO + ALA restoration inaccuracy increased the odds of postoperative dislocation (OR 12.056, 95% CI 1.409-103.127, P = 0.023; OR 4.770, 95% CI 1.336-17.028, P = 0.016, respectively). Combining the four risk factors of cup safe zone, HO, LLD, and ALA, patients with 3 or 4 radiologic restoration inaccuracy factors showed a higher risk of dislocation (OR 13.500, 95% CI 1.340-135.983, P = 0.027). CONCLUSION: Hip offset (HO) restoration inaccuracy increased the risk of dislocation following primary THA. Multivariate radiologic restoration accuracy is critical for the prevention of dislocation and needs to be valued by surgeons.

Review of complications, functional outcome, and long-term survival following conversion of hip fusion to total hip arthroplasty.

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.

The occurrence rate and clinical application of Osteo-line on the femur neck.

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.

A retrospective analysis of surgical outcomes following direct anterior hip arthroplasty with or without a surgical extension table.

PURPOSE: Using a surgical extension table during total hip arthroplasty (THA) is widely considered state-of-the-art. However, intra-operative leg positioning requires additional time and leg length determination can be challenging. Our study's aim was to compare patient outcomes, particularly leg length precision, following surgery with or without an extension table. METHODS: This retrospective study included data from medical records of 324 patients who underwent THA using the direct anterior approach by one surgeon at a Swiss cantonal hospital (2015-2017). Patients were grouped by table type-standard (TS) or extension table (TE). Variables analyzed were demographics, operative/anaesthetic conditions, and medical outcomes. The leg length was measured pre- and post-operatively with mediCAD Classic®. RESULTS: An extension table was used in 161 (49.7%) patients. The median operative duration (minutes) was shorter in TS (55 (interquartile range (IQR) 48-67) than TE (60 (IQR 54-69)) (p = 0.002) and blood loss (ml) was lower (TS = 400 (IQR 300-500), TE = 500 (IQR 300-600), p = 0.0175). The median post-operative leg length discrepancy (mm) was less in TS (TS = 1 (IQR 0-3), TE = 2 (IQR 0-4), p = 0.0122). All four dislocations occurred in TE, and 7.4% of patients had complications (TS = 7%, TE = 7.5%, p = 0.99). CONCLUSION: We found that operating on a standard table during THA resulted in slightly more favourable outcomes. Given the added expenses, human resources, and time associated with an extension table, opting for a standard table remains a sensible choice.

Only 8% of major preventable adverse events after hip arthroplasty are filed as claims: a Swedish multi-center cohort study on 1,998 patients.

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.

Congenital pseudarthrosis of the tibia: the outcome of a pathology-oriented classification system and treatment protocol.

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.

Femoral shortening does not impair functional outcome after internal fixation of femoral neck fractures in non-geriatric patients.

INTRODUCTION: Aim of this study was to investigate the incidence and extent of femoral shortening in non-geriatric patients after internal fixation of femoral neck fractures in relation to the clinical outcome at mid-term follow-up. MATERIALS AND METHODS: Reviewing our admission data, we identified non-geriatric patients (18-65 years) with femoral neck fractures treated with either dynamic hip screw or cancellous screws between 2007 and 2015. Patients were then contacted and invited to a follow-up clinical investigation including whole-leg standing X-rays. RESULTS: A total of 40 patients with a mean age at surgery of 52 ± 9 years returned for the follow-up examination. Overall, 31 patients (77.5%) had undergone a dynamic hip screw fixation, while 9 patients were treated with cancellous screws (22.5%). The median follow-up time was 65.5 months (5.5 years). We observed shortening of the ipsilateral femur neck in the majority of cases (92.5%). Still, functional outcome in the overall study population was excellent with a median Harris Hip Score of 96. CONCLUSIONS: Femoral neck shortening is common in non-geriatric patients after internal fixation of femoral neck fractures. Nonetheless, observed excellent functional outcome at mid-term follow-up supports joint-preserving strategies in non-geriatric femoral neck fractures.

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.

Perceived Leg-Length Discrepancy After Primary Total Knee Arthroplasty: Does Knee Alignment Play a Role?

Leg length discrepancy (LLD) is common after total knee arthroplasty (TKA) although its incidence has not been well documented. The purpose of this study was to determine the incidence of perceived LLD before and after primary total knee arthroplasty as well as to determine the correlation between mechanical axis of the knee and perceived LLD. The incidence and time frame of resolution of postoperative LLD was also assessed. Seventy-three patients were prospectively enrolled. Evaluation included patient surveys regarding perceived LLD preoperatively, and at 3- to 6-week, 3-month, 6-month, and 1-year visits. Mechanical axis radiographs were obtained and the relationship of mechanical axis in patients with and without perceived LLD, both before and after surgery, was determined. Analysis was also performed for separate varus and valgus deformities. The effect of surgery on patients' perception of LLD was also determined. Fifty-three patients did not perceive a LLD preoperatively and 18 perceived a LLD preoperatively. Sixty-four patients did not perceive a LLD postoperatively and 7 patients perceived a LLD postoperatively. There was a significant difference in patients who perceived LLD preoperatively and those who perceived LLD postoperatively (P = .035). Of the 7 patients with a perceived LLD postoperatively, all noted resolution of LLD at a mean of 8.5 weeks. There were no statistically significant correlations of knee alignment to perceived LLD in any patient groups. Body mass index and age did not demonstrate any statistical differences between patient groups. Perceived LLD is common in patients undergoing TKA; however, perceived LLD decreases after surgery. Although approximately 10% of patients perceive a LLD after surgery, the vast majority resolve within 3 months. Our study did not show any relationship between mechanical knee alignment and perception of LLD.

Femoral overgrowth in children with congenital pseudarthrosis of the Tibia.

BACKGROUND: Having observed a tendency towards femoral overgrowth (FO) of the affected limb in children with atrophic-type congenital pseudarthrosis of the tibia (CPT), we aimed to identify the incidence of, contributors to, and patterns of FO among such children. METHODS: We retrospectively evaluated 55 children with CPT, 22 with prepseudarthrosis and 33 with atrophic-type CPT from 1989 to 2012. FO was defined as an affected femoral segment ≥10 mm longer than the contralateral segment. We investigated FO incidences in prepseudarthrosis versus atrophic-type CPT. Sex, laterality, coexistence of neurofibromatosis type 1, development of frank pseudarthrosis, extent of tibial shortening, shortening in foot height, deformity severity, distraction osteogenesis (DO) treatment, refracture, increased femoral neck-shaft angle, tibiofemoral angle, and ankle valgus angle were investigated to identify potential contributors to FO. Patterns of FO were also determined. RESULTS: At initial presentation, 11 patients exhibited a mean of 13 mm (10-23) of FO. However, the nature of FO changed over time during the follow-up period (mean, 10.8 years; range, 4.3-19.3). At the last follow-up, 14 patients presented with a mean of 12 mm (10-18) of FO. With the exception of one patient, all patients with FO presented with atrophic-type CPT. Frank pseudarthrosis, DO treatment, and increased femoral neck-shaft angle were significantly associated with FO (p = 0.016, p = 0.001, and p = 0.005, respectively). Diverse patterns of FO were observed. CONCLUSIONS: FO of the affected limb is frequently encountered in patients with atrophic-type CPT. A compensatory response to frank pseudarthrosis, DO treatment, and neurofibromatosis may play a role in the diverse patterns of FO.

Hip Instability in Down Syndrome: A Focus on Acetabular Retroversion.

BACKGROUND: The aim of this study is to compare acetabular anteversion between children with Down syndrome with or without hip instability. The second aim is to report the surgical experience at our institution in treating unstable hips for this population. METHODS: All children with Down syndrome who were seen at our institution between 2004 and 2014 were reviewed, and those who had pelvic axial computed tomographic or magnetic resonance imaging scans were identified. Acetabular anteversion was compared between 2 groups: those with hip instability as a single hip pathology and those without hip instability. For patients who had surgery for their unstable hips, demographic, clinical, and surgical data were recorded. Preoperative and last visit radiographs were reviewed. Extrusion index and Tonnis, Sharp, lateral center edge, and neck shaft angles were measured. Presence of Shenton's line disruption, crossover, and posterior wall signs were recorded. Independent and paired t test, Wilcoxon signed-rank test, and χ test were used with a significance level at 0.05. RESULTS: Out of 308 children with Down syndrome, there were 10 patients with 13 unstable hips and 13 patients with 26 stable hips who had computed tomographic or magnetic resonance imaging scans. Age and sex distributions were similar (P>0.3) with no difference in acetabular anteversion (P=0.926) between them. Twelve patients (6 boys and 6 girls) had reconstruction for 17 hips. The mean age was 9 years (3 to 15 y) and the mean follow-up was 7 years (1.2 to 17.6 y). Five hips were painful preoperatively and 1 hip was painful at last visit. Radiographic measurements improved significantly (P<0.05). Shenton's line disruption was found in fewer hips (P=0.001) at last visit with no difference in the crossover and posterior wall signs (P=0.177). CONCLUSIONS: This report suggests that a wide range of acetabular anteversion measurements exist in children with Down syndrome. After detailed anatomic study of the hip, good results with a low complication rate can be expected over the intermediate term after hip reconstruction. LEVEL OF EVIDENCE: Level IV-prognostic and therapeutic study.

Patients' perception of leg length discrepancy post total hip arthroplasty.

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.

Accuracy of Component Positioning in 1980 Total Hip Arthroplasties: A Comparative Analysis by Surgical Technique and Mode of Guidance.

The purpose of this multi-surgeon study was to assess and compare the accuracy of acetabular component placement, leg length discrepancy (LLD), and global offset difference (GOD) between six different surgical techniques and modes of guidance in total hip arthroplasty (THA). A total of 1980 THAs met inclusion criteria. Robotic- and navigation-guided techniques were more consistent than other techniques in placing the acetabular cup into Lewinnek's safe zone (P<0.005 and P<0.05, respectively). Robotic-guided surgery was more consistent than other techniques in placing the acetabular component within Callanan's safe zone (P<0.005). No statistically significant differences were found between groups in the frequency of patients with excessive LLD. Clinically significant differences between groups were not found in the frequency of patients with excessive GOD. Level of Evidence: IV.

The painful primary hip replacement - review of the literature.

Total hip replacement is one of the most successful surgical procedures of the 20th century (World Health Organisation). The success rate is dependent on the chosen endpoint. Evaluation of the outcome in joint replacement surgery has shifted from the revision rate toward patient satisfaction and quality of life. Patient satisfaction is reported to be up to 96% 16 years postoperatively, but the prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series. The aim of our article is to review the aetiology, diagnostic procedures and treatment of the painful primary total hip replacement. We discuss the most relevant intrinsic and extrinsic aetiological factors responsible for chronic pain after total hip arthroplasty focusing on comparative studies and randomised controlled trials including diagnostics and management. Detailed analysis of history, clinical examination, imaging and laboratory tests are required prior to any revision for painful total hip arthroplasty. Revision surgery without knowing the underlying pathology should be avoided.

Algorithm for the management of femoral shaft fractures in children.

PURPOSE: Pediatric closed femoral shaft fractures are commonly related to a good prognosis. There is no consensus on treatment. We aimed to evaluate the treatment, features, radiological findings and management strategies, creating an algorithm of treatment. MATERIALS AND METHODS: Fifty-two simple femoral shaft fractures in children were retrospectively evaluated for age and gender distribution, side of the fracture, etiology of injuries, limb length discrepancy, range of knee and hip motion and parents satisfaction with a mean clinical and radiographic follow-up of 3 years and 6 months. Twenty-eight patients were treated with reduction and early hip spica cast while 24 patients were treated with external fixation (EF). RESULTS: Nearly 58 % of the cases were caused by traffic accidents and were predominantly male (61.5 %). Most of the fractures were of the middle femoral shaft (57.6 %). Muscle strength was normal (MRC scale) in all patients with no pain (NIPS and PRS scale). Knee and Hip range of motion were similar in both types of treatment. Patients treated with EF had shorter limb length discrepancy compared with SC. There were no reports of re-fracture. We found a higher familiar satisfaction in patients treated with EF. CONCLUSIONS: An algorithm for the management of femoral shaft fractures in the pediatric population is proposed. Results on the study population gave raise to a satisfactory clinical and radiological results.

Cost effectiveness of using surgery versus skeletal traction in management of femoral shaft fractures at Thika level 5 hospital, Kenya.

INTRODUCTION: A prospective quasi experimental study was undertaken at the Thika level 5 hospital. The study aimed to compare the costs of managing femoral shaft fracture by surgery as compared to skeletal traction. METHODS: Sixty nine (46.6%) patients were enrolled in group A and managed surgically by intramedullary nailing while 79 (53.4%) patients were enrolled in group B and managed by skeletal traction. Exclusion criteria included patients with pathological fractures and previous femoral fractures. Data was collected by evaluation of patients in patient bills using a standardized questionnaire. The questionnaire included cost of haematological and radiological tests, bed fees, theatre fees and physiotherapy costs. The data was compiled and analyzed using SPSS version 16. Person's chi square and odds ratios were used to measure associations and risk analysis respectively. RESULTS: A higher proportion of patients (88.4%) in group A were hospitalized for less than one month compared to 20 patients (30.4%) in group B (p, 0.001).Total cost of treatment in group A was significantly lower than in group B. Nineteen (27.9%) patients who underwent surgery paid a total bill of Ksh 5000-7500 compared to 7(10.4%) who were treated by traction. The financial cost benefit of surgery was further complimented by better functional outcomes. CONCLUSION: The data indicates a cost advantage of managing femoral shaft fracture by surgery compared to traction. Furthermore the longer hospital stay in the traction group is associated with more malunion, limb deformity and shortening.

Comparison of submuscular and open plating of pediatric femur fractures: a retrospective review.

BACKGROUND: Plate osteosynthesis is an accepted method of treatment of pediatric femur fractures. Historically, open plating has been used. Submuscular bridge plating has gained recent popularity due to the theoretical advantages of decreased operative time, decreased blood loss, and decreased risk for infection. The purpose of this study was to compare submuscular bridge plating to open plating of pediatric femur fractures. METHODS: We retrospectively reviewed 79 patients (80 treated femur fractures) between 1999 and 2011 that underwent either open plating (58 femur fractures) or submuscular bridge plating (22 femur fractures). The outcome measures evaluated were operative time, estimated blood loss, malunion, leg length discrepancy, time to union, infection, unplanned return to the operating room, and length of hospital stay after surgery. RESULTS: Among our outcome measures, there was no difference between the 2 groups in terms of operative time, leg length discrepancy, time to union, infection, or length of hospital stay after surgery. There was greater estimated blood loss in the open plating group (P≤0.0001) and greater rotational asymmetry in the submuscular bridge plating group (P=0.005). There was a trend of increased unplanned return to the operating room in the open plating group (5/58 vs. 0/22) although not statistically significant (P=0.32). CONCLUSIONS: Submuscular bridge plating and open plating seem to be equally viable options for the management of pediatric diaphyseal femur fractures. In this study, open plating had an increase in estimated blood loss and a trend of more unplanned returns to the operating room, whereas submuscular bridge plating had an increase in asymptomatic rotational asymmetry. Further larger, prospective, randomized studies are necessary to further evaluate these operative techniques. LEVEL OF EVIDENCE: Therapeutic Level III.

Comparison of limb-length discrepancy after THA: with and without computer navigation.

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.