External fixator-assisted acute shortening with internal fixation for leg length discrepancy after total hip replacement

Abstract

We report a case of a 51-year-old lady, who underwent a femoral shortening using a fixator assisted blade plate after total hip replacement. The patient had a total hip replacement on the other side with previous revisions, which resulted in a leg length discrepancy. We used the above technique to control the shortening and preserve the mechanical and anatomical axis of the femur.Keywords External fixator Á Femoral shortening Á Total hip replacement Case reportA 35-year-old lady with a history of neglected developmental dysplasia (DDH) of the right hip presented with increasing hip pain, back pain and progressive knee deformity. She subsequently underwent conversion of the pseudoarthrosis to a total hip replacement. At the time of surgery, despite adductor tenotomy, it was difficult to relocate the trial prosthesis and a resection of the proximal femur was necessary. A straight stem prosthesis was cemented in the femur (Fig. 1).Ten years later the patient required a revision of the acetabular component as a consequence of aseptic loosening. The acetabular reconstruction was undertaken using a cemented socket and with impacted bone graft. The reconstruction lasted for 9 more years before a further revision was required. There was extensive bone loss in the acetabulum and the reconstruction was performed using a Burch Schneider support ring, mesh and again with impaction bone graft. The bone stock in the proximal femur was so poor that a proximal femoral allograft with an uncemented stem was used to reconstruct the proximal femur. A leg length discrepancy of 5 cm remained.Increasingly symptomatic osteoarthritis in the left hip necessitated a left primary arthroplasty to be performed 3 years later. Six months after the left THR (age 51), she presented with increasing back pain attributed to a 5-cm discrepancy in leg length (Fig. 2). Shortening of the left femur was done by performing an external fixator-assisted shortening through a supracondylar resection and internal stabilisation with a blade plate. Operative techniqueA limb reconstruction system (LRS) external fixator (Orthofix SRL, Italy) with four screws (150/50) was inserted in the sagittal plane under X-ray control perpendicular to the anatomical axis of the femur. Two screws were inserted above and two below the proposed level of femoral resection (Fig. 3). Through a lateral incision and subperiosteal approach a 4-cm segment of the distal femur was removed. The femur was then gradually shortened using the compression-distraction device on the fixator until bone contact at the edges of the osteotomy was achieved. With the fixator still in place, the newly shortened femur

Limb-length Discrepancy After Total Hip Arthroplasty: Novel Treatment and Proposed Algorithm for Care

“…Shortening of the ipsilateral thigh has been reported. 28 To the current authors' knowledge, this is the first reported series of patients who underwent contralateral lengthening for the treatment of symptomatic leg-length discrepancy after THA.…”

“…In these instances, patients have few options. Kasis et al 28 described a patient with a 5-cm limb-length discrepancy who underwent shortening of the ipsilateral femur. A contralateral limb-lengthening osteogenesis was not possible because the contralateral (short) limb had undergone a longstem revision THA and therefore could not be treated with intramedullary limb lengthening.…”

Total Hip Arthroplasty for Crowe Type IV Hip Dysplasia: Surgical Techniques and Postoperative Complications

“…introduced a surgical technique for contralateral leg lengthening to correct LLD. If contralateral leg lengthening is contraindicated, shortening of the THA leg may be considered.…”

Cemented Versus Cementless Primary Hip Replacement: Assessment of Leg Length Inequality

“…These include revision HA, ipsilateral limb shortening or contralateral HA. 22,23 Each of these procedures has its drawbacks or limitations, e.g. using insole lift can correct only small inequality while using lift outside the shoes for larger inequality is unsightly and when the shoes are off the inequality returns.…”