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Background: Selective neurectomy or muscle resection techniques for calf reduction conventionally focus on the gastrocnemius muscle. However, the underlying soleus muscle plays an important role in muscular calf hypertrophy. In the authors' experience, the results of calf reduction have been suboptimal in patients with severe muscular calf hypertrophy who underwent gastrocnemius muscle resection only. This article describes a new calf reduction method that uses concurrent gastrocnemius muscle resection and soleus muscle neurectomy using an endoscope-assisted single-incision approach in patients with severe muscular calf hypertrophy., Methods: A total of 139 patients who underwent simultaneous gastrocnemius muscle resection and soleus muscle neurectomy for severe calf hypertrophy from March of 2017 to June of 2020 were retrospectively analyzed., Results: After combined gastrocnemius resection (mean weight per calf, 349 g) and soleus neurectomy, about 3.8 to 8.2 cm (mean, 6.4 cm) or 12.8% to 24.3% (mean, 16.6%) of the calf was reduced. Complications included cellulitis, hematoma, seroma, and mild depression ( n = 1 each). Two patients had traction injury to the sural nerve. One patient developed Achilles tendon rupture at 2 months postoperatively. No patient complained of functional impairment with respect to easy fatigability, stability, gait, or sport activities at 6 months postoperatively., Conclusion: This study is the first to combine gastrocnemius muscle resection with selective soleus muscle neurectomy to achieve the most efficient calf reduction for severe muscular calf hypertrophy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver., Materials and Methods: This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t-tests and effect size (Cohen's d). Statistical significance was set at P < .05., Results: Tablet-based AR procedural training significantly improved procedural knowledge (P < .001), tablet-based procedural skills (P < .001), and reduced tablet-based procedural time (P < .002). Effect sizes were very large for tablet-based procedural knowledge (d = 1.75) and skills (d = 3.2) and small (d = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver., Conclusions: Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Even after the endovascular revolution, acute compartment syndrome (CS) remains an important and frequently present differential diagnosis after many operations. Based on a qualitative review this article gives an overview of the most frequent forms of CS as well as some less frequent entities that require attention in the routine clinical practice. Additionally, the pathophysiology, diagnostics and treatment as well as current research topics for CS, especially concerning the lower leg, are dealt with in detail. In summary, nothing has essentially changed ever since the first description of CS in that the clinical estimation remains the gold standard. The detection and the adequate treatment especially of abdominal CS and CS of the lower leg remain a key competence of vascular surgeons., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

For centuries scientists and technologists have sought artificial leg replacements that fully capture the versatility of their intact biological counterparts. However, biological gait requires coordinated volitional and reflexive motor control by complex afferent and efferent neural interplay, making its neuroprosthetic emulation challenging after limb amputation. Here we hypothesize that continuous neural control of a bionic limb can restore biomimetic gait after below-knee amputation when residual muscle afferents are augmented. To test this hypothesis, we present a neuroprosthetic interface consisting of surgically connected, agonist-antagonist muscles including muscle-sensing electrodes. In a cohort of seven leg amputees, the interface is shown to augment residual muscle afferents by 18% of biologically intact values. Compared with a matched amputee cohort without the afferent augmentation, the maximum neuroprosthetic walking speed is increased by 41%, enabling equivalent peak speeds to persons without leg amputation. Further, this level of afferent augmentation enables biomimetic adaptation to various walking speeds and real-world environments, including slopes, stairs and obstructed pathways. Our results suggest that even a small augmentation of residual muscle afferents restores biomimetic gait under continuous neuromodulation in individuals with leg amputation., (© 2024. The Author(s).)

Background: Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%., Hypothesis: Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy., Study Design: Retrospective cohort study., Level of Evidence: Level 4., Methods: We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant., Results: A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest ( P = 0.05) and with daily activity ( P = 0.04), reduced postoperative improvement in Tegner scores ( P = 0.04), and lower odds of return to sport ( P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency ( P < 0.01), pain severity at rest ( P < 0.01) and with daily activity ( P = 0.04), and return to sport ( P = 0.04)., Conclusion: ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia., Clinical Relevance: Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy., Competing Interests: The following author declared potential conflicts of interest: L.M.J. received grants or has pending grants from Arthrex, Mitek, and Smith & Nephew; and received publishing royalties from Wolters Kluwer Health - Lippincott Williams & Wilkins.

Rationale: A hostile iliac access route is an important consideration when enforcing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). Herein, we report a case of AAA with unilateral external iliac artery occlusion, for which bifurcated EVAR was successfully performed using a single femoral and brachial artery access., Patient Concerns: A 76-year-old man who had undergone surgery for lung cancer 4.5 years prior was diagnosed AAA by computed tomography (CT)., Diagnosis: Two and a half years before presentation, CT revealed an infrarenal 48 mm AAA, which had enlarged to 57 mm by 2 months preoperatively. CT identified occlusion from the right external iliac artery to the right common femoral artery, with no observed ischemic symptoms in his right leg. The right external iliac artery, occluded and atrophied, had a 1 to 2 mm diameter., Intervention: Surgery was commenced with the selection of a Zenith endovascular graft (Cook Medical) with an extended body length. Two Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associate) were delivered from the right axilla as the contralateral leg., Outcomes: CT scan on the 2nd day after surgery revealed no endoleaks., Lessons: While the long-term results remain uncertain, this method may serve as an option for EVAR in patients with unilateral external iliac artery occlusion., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: In some cases, patients feel a perceived leg length discrepancy (P-LLD) despite no radiographic leg length discrepancy (R-LLD) after total hip arthroplasty (THA). We aimed to investigate the rate of postoperative P-LLD and the factors that cause postoperative P-LLD., Methods: A retrospective study was conducted on 100 patients with R-LLD ≤5 mm after THA. Patients were classified into two groups based on P-LLD post-THA: group P (with P-LLD) and group E (without P-LLD). Relevant data on the general characteristics and radiological findings between the two groups were compared., Results: We observed that 25 & 75% of patients belonged to group P and group E, respectively, with no significant difference in patient background. Postoperative Japanese Orthopedic Association (JOA) classification of pain and activities of daily living scores were significantly lower in group P than in group E (37.2 ± 3.9 vs. 39.1 ± 2.2, respectively; P = 0.013, and 16.2 ± 4.2 vs. 18.2 ± 2.2, respectively; P = 0.011). The preoperative pelvic oblique angle (POA) was significantly larger in group P than in group E (3.3 ± 2.3° vs. -0.2 ± 2.1°; respectively; P < 0.01). The pelvis tilted toward the surgical side was significantly higher in group P than in group E(88% vs 57%; respectively; P = 0.013). The preoperative C7 coronal vertical axis (C7 CVA) was significantly larger in group P than in group E (6.7 ± 14.7 mm vs. -0.2 ± 10.3 mm; respectively; P = 0.028). Multivariate logistic analysis revealed that preoperative POA (OR, 3.71; 95% CI: 1.86-8.12; P < 0.01) and the pelvis tilted toward the surgical side (OR, 4.14; 95% CI: 2.07-9.71; P = 0.022) were independent risk factors for P-LLD after THA., Conclusion: Even though there was no postoperative R-LLD, 25% of patients had P-LLD. A large preoperative POA and the pelvis tilted toward the surgical side were independent risk factors for P-LLD after THA., Competing Interests: Declaration of competing interest All authors declare that they have no conflict of interest., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objective: Soft tissue repair of the distal leg is a challenge for the surgeon. The objective of our work is to evaluate the interest of medial plantar flaps in the repair of soft tissue loss in the distal quarter of the leg, by highlighting the advantages and disadvantages of this technique., Methods: We conducted a retrospective study over 4 years in the Department of Plastic, Reconstructive and Burn Surgery of the Mohammed V Military Teaching Hospital of Rabat, including 8 patients admitted for coverage of a distal quarter of the leg with a medial plantar flap., Results: Eight patients were included, 5 men and 3 women with an average age of 45.5 years. All patients received coverage with a medial plantar flap. The functional and aesthetic results were very good with a low complication rate., Conclusion: The medial plantar flap should no longer be reserved for covering loss of substance of the foot only, but should be integrated into the therapeutic arsenal of reconstruction of the distal quarter of the leg., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: To observe the residual of lumbago and leg pain with contained type （CT） and non-contained type （NCT） lumbar disc herniation （LDH） after transforaminal endoscopic treatment, and to explore the role of hypoxia-inducible factor-1α（HIF-1α） and transient receptor potential vanillate 1（TRPV1） pathway., Methods: A total of 68 single-segment LDH patients were selected from July 2021 to October 2022, including 44 males and 24 females；aged 26 to 67 years old with an average of（43.63±11.94） years old；course of disease was 4 to 36 （18.91±10.34） months；body mass index was （24.45±4.00） kg·m -2 ；there were 7 cases of L 3,4 segments, 32 cases of L 4,5 segments, and 29 cases of L 5 S 1 segments. All of them were performed with percutaneous intervertebral endoscopic extraction of nucleus pulposus and were divided into contained group（CT group） and non-contained group （NCT group） with 34 cases respectively according to the integrity of outer layer of fibrous annulus observed during operation. A total of 17 patients who underwent open surgery for scoliosis or vertebral fracture were selected as control group, including 12 males and 5 females；aged 21 to 65 years old with an average of （39.41±12.80） years old；body mass index was （24.86±4.11） kg·m -2 . The relative mRNA expression quantity of HIF-1α, TRPV1 in nucleus pulposus were measured by quantitative real-time PCR. The contents of neurokinin 1 receptor （NK1R）, nerve growth factor （NGF）, vascular endothelial growth factor （VEGF） in nucleus pulposus and the serum substance P （SP） and calcitonin gene-related peptide （CGRP） were detected by enzyme linked immunosorbent assay （ELISA）. The threshold of lumbar tenderness was detected by a pressure pain meter. The degree of lumbago and lumbar function were evaluated by visual analog scale （VAS） and Oswestry disability index （ODI） separately. The residual rate of postoperative lumbago and leg pain was assessed., Results: The mRNA relative expression quantity of HIF-1α and TRPV1, and the contents of NK1R, NGF and VEGF in nucleus pulposus, and the levels of serum SP and CGRP before surgery in the NCT group were higher than those in the CT group（ P <0.05）, and those in the CT group were higher than the control group（ P <0.05）. At day 7 after surgery, the serum SP and CGRP levels, lumbago and leg pain VAS scores and lumbar ODI index in two LDH groups were lower than before surgery （ P <0.05）, and those in the NCT group were higher than the CT group（ P <0.05）, and the threshold of lumbar tenderness in the NCT group was lower than the CT group（ P <0.05）. The differences of lumbago and leg pain VAS scores, lumbar ODI index and lumbar tenderness threshold between preoperative and postoperative 7 days in the NCT group were lower than those in the CT group（ P <0.05）. The residual rate of lumbago and leg pain at 7 days after surgery in the NCT group was higher than that in the CT group（ P <0.05）., Conclusion: HIF-1α and TRPV1 pathway promoted the excessive production of NGF, VEGF, NK1R in nucleus pulposus and serum neuropeptides SP and CGRP, which may lead to the higher residual rate of lumbago and leg pain with non-contained lumbar disc herniation postoperative.

Background: Some patients with lumbar spine stenosis (LSS) have severe low back pain (LBP) with only mild leg symptoms. The effects of decompression surgery for such patients remain unknown., Methods: Of 818 patients with LSS who underwent surgical treatment in our institution from 2011 to 2019, eight patients had a numeric rating scale (NRS) score of ≥7 for LBP and 3≤ for leg pain. The patients' age, sex, clinical characteristics, preoperative leg symptoms, and level of LSS were investigated. The detailed characteristics of LBP, such as the disease duration, location of LBP, and exacerbating factors, were obtained from each patient. The NRS and Japanese Orthopaedic Association (JOA) scores for LBP were evaluated on admission, at 1 and 3 months postoperatively, and at the final follow-up (>1 year postoperatively)., Results: All patients were male with a mean age of 71.5 years (range, 57-82 years). LBP was exacerbated during walking in six patients and during an extension posture in three patients. The median duration of LBP was 2.9 years (range, 0.3-7 years). The stenosis was located at L2/3 in three patients, L3/4 in five patients, and L4/5 in seven patients. The stenosis involved one level in three patients and more than two levels in five patients. Other pathologies, such as sacroiliac joint lesions, facet pain, superior/middle cluneal nerve pain, and discogenic pain, were excluded by diagnostic anesthetic block and detailed physical examination. All patients underwent posterior decompression surgery without fusion. In all eight patients, the NRS score for LBP significantly improved from 7.6 (range, 7-10) to 1.7 (range, 0-3) and the JOA score improved from 13.1 (range, 4-19) to 21.8 (range, 18-27)., Conclusion: A low proportion of patients showed walking-evoked severe LBP with mild leg symptoms due to lumbar spine stenosis. The patients' pain was improved by decompression surgery with satisfactory results.

Background: Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension., Methods: This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended., Results: The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established., Level of Evidence: Level III: retrospective cohort study., Competing Interests: Conflict of Interest None., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Although amputation rates, morbidity, and mortality have been established for select populations, the impact of general demographic factors on postoperative surgical complications remains little studied., Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was searched for leg amputations from 2012 to 2017 using CPT codes 27881, 27882, 27884, and 27886, identifying 4162 patients. A total of 29 demographic variables with 4 complications (surgical infection, additional service, and deep-vein thrombosis [DVT], and sepsis) were analyzed., Results: Preoperative open, contaminated, or dirty/infected wounds; longer intraoperative times; development of sepsis prior to surgery; and admission of patients from home or another hospital influenced postoperative infection rates. Preoperative open, infected, or dirty/infected wounds; height; weight; total length of hospital stay; and ethnicity affected postoperative additional service incidence. Preoperative congestive heart failure, large decreases in body weight, and total length of hospital stay influenced postoperative DVT rates. Preoperative functional heath status, total length of hospital stay, amputations conducted as emergency cases, preoperative acute renal failure, open or infected wounds, sepsis, and contaminated or dirty/infected wounds affected postoperative sepsis rates., Background: Conclusion. Understanding these risk factors may allow providers to anticipate and address higher rates of complications in certain patient populations., Level of Evidence: Level III: Prognostic ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Vinod K. Panchbhavi is a consultant for Stryker Orthopaedics as well as an editor for Lippincott Williams and Wilkins Publishing. The other authors have nothing to disclose.

Summary: To achieve a more aesthetic and narrower columella, most of the required changes concern the middle and base of the columella. Narrowing and reshaping the columellar base require a sequential approach with good anatomical knowledge and aesthetics analysis. The columellar base is a three-dimensional structure that must be analyzed following three axes: transverse (thickness or width), frontal (height), and sagittal (nasolabial angle). Sutures that aim to close the distance between the medial crura footplates frequently result in modifying the nasolabial angle because of caudal protrusion of the columellar soft tissue. Methods to keep an adequate nasolabial angle are needed. A transverse columellar base stabilizing suture acting on these three axes, which enables maintenance of results after columellar base management, is described in this article., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Competing Interests: Conflicts of interest None disclosed.

Techniques that reduce mechanical energy have been linked to lower chances of experiencing an Anterior Cruciate Ligament (ACL) injury. Although there is evidence that movement patterns are altered in athletes who have undergone Anterior Cruciate Ligament Reconstruction (ACLR), energy transfer mechanisms have not been examined. This study aimed to compare energy flow mechanisms during single-leg drop landing between athletes with and without history of ACLR. A total of 20 female athletes were included in this study. Ten participants underwent ACLR 12 months ago (mean age, 21.57 ± 0.41 years) and 10 were healthy controls (mean age, 20.89 ± 0.21 years). Participants executed the single-leg drop landing (SLL) maneuver by descending from a 30 cm wooden box and landing on the tested leg on an embedded force plate. Information collected during the SLL trials was refined using rigid-body analysis and inverse dynamics within Nexus software, ultimately allowing construction of skeletal models of the athletes. Ankle and knee mechanical energy expenditure (MEE) was higher in the control participants during landing. However, the result for the hip MEE demonstrated that MEE of the control group was significantly lower compared with the ACLR group, but MEE of the control subjects was higher as compared to ACLR group (p ˂ 0.05). Results suggest the avoidant use of the quadriceps muscle post ACLR leads to knee-avoidant mechanics and loss of knee joint power generation during a SLL task., (© 2024. The Author(s).)

Correction of leg length discrepancy (LLD) in skeletally mature patients with osteosarcoma was rarely reported and quite challenging. This study aimed to propose a treatment strategy of staged lengthening and reconstruction with a standard static prosthesis to address LLD and restore limb function. It also evaluated the effectiveness of the strategy in terms of leg lengthening, functional outcomes, and complications. The strategy for lengthening included three stages. In stage 1, the previous prosthesis was removed and an external fixator with a temporary rod-cement spacer was placed. In this stage, the external fixator was used to lengthen the limb to the appropriate length. In stage 2, the external fixator was removed and the old rod-cement spacer was replaced with a new one. In stage 3, the rod-cement spacer was removed and the standard static prosthesis was planted. Nine skeletally mature distal femoral osteosarcoma patients with unacceptable LLD were treated in our institution from 2019 to 2021. We performed a chart review on nine patients for the clinical and radiographic assessment of functional outcomes, LLD, and complications. The mean (range) leg lengthening was 7.3 cm (3.6-15.6). The mean (range) LLD of the lower limbs decreased from 7.6 cm (4.1-14.2) before the lengthening to 0.3 cm (- 0.3 to 2.1) at the final follow-up with statistical significance (P = 0.000). The mean (range) Musculoskeletal Tumor Society score improved from 30.3% (16.7%-53.3%) before the lengthening to 96.3% (86.7%-100%) at the final follow-up with statistical significance (P = 0.000). Three patients (33.3%) had a minor complication; none needed additional surgical intervention. In the short term, the current staged lengthening and reconstruction with standard static prosthesis provided satisfactory functional outcomes and LLD correction with few complications. The long-term effects of this method need further exploration., (© 2024. The Author(s).)

Background: Change in leg length and leg-length discrepancy (LLD) are common concerns among patients undergoing medial unicompartmental knee arthroplasty (UKA). This study aimed to quantify the magnitude of leg-length change, prevalence of postoperative LLD, and their clinical implications following medial UKA., Methods: Leg length and mechanical hip-knee-ankle angle (mHKA) were retrospectively measured in 332 patients following unilateral robotic-arm assisted medial UKA for medial compartment osteoarthritis, using calibrated long-leg radiographs. The Knee Injury and Osteoarthritis Otcome Score for Joint Replacement and patient satisfaction were analyzed to assess impact of leg-length change and LLD on outcomes., Results: Following medial UKA, median leg-length change was 2.0 mm (interquartile range, -1.0 to 5.0 mm; P < .001) with a mean correction in mHKA of 4.4° ± 2.7 (P < .001). A total of 158 patients (48%) had a leg-length increase by 0 to 5 mm, 64 (19%) by 6 to 10 mm, and 11 (3%) by >10 mm. Leg-length change was positively correlated with mHKA correction (R = 0.44, P < .001). Postoperatively, moderate (5 to 10 mm) and substantial LLD (≥10 mm) were present in 49% and 17% of patients, respectively. Four-year Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were comparable between patients with and without substantial postoperative LLD (P = .976). Proportions of satisfied patients were similar between groups (P = .687)., Conclusion: Following medial UKA, the majority of patients had a moderate increase in leg length, the magnitude of which was positively correlated to the correction in mechanical alignment. Postoperative substantial LLD was not uncommon (17% prevalence); however, it had no significant impact on patient-reported outcomes or satisfaction at 4 years follow-up., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To investigate the architecture of the cutaneous branch-chained blood vessels in the medial lower leg and provide the anatomical basis for design and clinical application of the cutaneous branch-chained flap from this region. Methods: The experimental research method was used. From March to May 2023, the anatomical study was conducted on the 5 voluntarily donated fresh adult (aged 50 to 70 years, all male) cadaveric specimens from Hangzhou Normal University School of Basic Medical Sciences. The fine anatomy under microscope was performed on each lower leg specimens of 5 corpses (1 lower leg specimen was conducted with digital radiography (DR) scan before fine anatomy), to observe, measure, and record the course of posterior tibial artery, quantity of perforator, the distance between the perforating point of each perforator and the medial condyle of tibia, the external diameter of posterior tibial artery perforator, the length of perforator pedicle, the horizontal distance between the posterior tibial artery perforator and the saphenous nerve, and the course of each perforator within superficial fascia after crossing the deep fascia and the distribution of the cutaneous branch-chains. The DR scan under the perfusion of barium sulfate was conducted in one lower leg specimen to observe the distribution of cutaneous branch-chained vascular network (hereinafter referred to as vascular chain) between perforators. Transparent skin specimen was made from one leg specimen after anatomy to observe the distribution of perforators and vascular chains between perforators. Results: In 5 lower leg specimens, the upper part of posterior tibial artery was located deep in soleus muscle, and the lower part was located between the medial edge of gastrocnemius muscle and flexor digitorum longus muscle. A total of 28 posterior tibial artery perforators were identified, with an average of 5.6 branches in each lower leg. The distance between the perforating point of perforator and the medial condyle of tibia ranged from 6.5 to 36.0 cm, mainly distributed at 22.0 (15.1, 28.1) cm from the medial condyle of tibia, in zones 3 to 6. The external diameters of perforators of posterior tibial arteries were 0.7-1.1 mm. The length of perforator pedicle was 1.0-4.5 cm, and the horizontal distance between the posterior tibial artery perforator and the saphenous nerve was 0.5-3.0 cm. The fine anatomy under microscope showed that the posterior tibial artery perforators had long upward and downward branches after crossing the deep fascia, and the ascending branches and descending branches were anastomosed longitudinally to form the nutrient cutaneous branch-chain in the medial lower leg. DR scan and transparent skin specimen both showed that longitudinal vascular chain was formed between the posterior tibial artery perforators, the transparent skin specimen also showed that longitudinal blood vessel chains included the direct connecting vessels in the adipose layer and the indirect connecting vessels in the subdermal layer. Conclusions: The cutaneous branch-chained vessels in the medial lower leg are constructed by posterior tibial artery perforators, direct connecting vessels, indirect connecting vessels, and traffic branches. The cutaneous branch-chained flap is reliable in terms of vascular anatomy, and can carry the saphenous nerve for partial restoration of its sensation, thus it is an ideal flap.

Case: A 50-year-old man presented with chronic refractory symptoms of radiating leg pain with muscle cramps because of a retained bullet in the calf after being shot in 1990. Radiographs confirmed the bullet lodged in posterolateral aspect of calf abutting proximal fibula. An intraoperative point-of-care ultrasound aided in accurate localization of bullet, thereby facilitating precise planning of surgical incision and subsequent removal., Conclusions: Ultrasound can be used as an alternative tool for safe surgical extraction of deep-seated metallic object with minimal tissue dissection, obviating the need for C-arm., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C191)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications., Methods: All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively., Results: Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned., Conclusions: CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Various methods have been attempted to improve the size and shape of calves, and selective neurocoagulation of the calf muscle using radio frequency (RF) is one of them. The objective of this study was to provide information about the efficacy and safety of selective neurocoagulation of the gastrocnemius (GCM) and lateral soleus muscles using RF for cosmetic purposes., Methods: A retrospective analysis of 345 patients (686 legs), who underwent selective neurocoagulation using RF at our clinic for calf hypertrophy between January 2018 and March 2020, was performed. We measured the circumference of the calf and thickness of the medial GCM using ultrasonography before and after the procedure. Patient satisfaction and side effects were investigated through interviews., Results: The average calf circumference had decreased by 2.9 ± 1.1 cm (GCM-only group) and 3.0 ± 1.4 cm (GCM + lateral soleus group), at 6 months after the procedure, and there was a statistically significant decrease in both groups. At 12 months after the procedure, the calf circumference slightly increased compared to that at 6 months, but the circumference was still smaller than that before the procedure. Most patients were satisfied with the size and contour of their calves and there were no severe adverse effects., Conclusions: Motor nerve coagulation using RF was effective in reducing the volume of the GCM and lateral soleus muscles and softening the contours of the calf. It was safe and without side effects in most patients., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: While using lymphovenous anastomosis (LVA) to treat extremity lymphedema, an antegrade lymphatic-to-venous flow is usually considered to indicate a functional and effective anastomosis. The authors analyzed the characteristics of lymphovenous anastomoses in patients with extremity lymphedema to look for the deciding factors of the flow direction., Methods: A total of 45 patients (15 arms and 42 legs) undergoing LVA for extremity lymphedema were reviewed. Only the anastomoses with intraoperatively confirmed patent flow or clear visualization of vessel lumens during anastomosis were included for analysis. Multivariate logistic regression was used to identify the contributing factors of intraoperative washout phenomenon or venous reflux., Results: A total of 105 eligible LVAs were included for analysis. Anastomosis with a more sclerotic lymphatic duct is statistically significantly associated with more venous reflux (OR, 2.82; P = 0.003). Larger diameter difference between lymphatic duct and recipient vein (OR, 12.8; P = 0.02) and less sclerotic lymphatic duct (OR, 0.47; P = 0.03) are statistically significantly associated with more washout phenomena., Conclusions: The deciding factors of flow direction in LVA are difference of diameters between lymphatic duct and recipient vein, and the severity of lymphosclerosis. To obtain favorable antegrade lymph-to-vein flow, a less sclerotic lymphatic duct with larger diameter and a recipient vein with smaller diameter should be chosen for anastomosis., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Chronic exertional compartment syndrome involving the lower leg lateral compartment (lat-CECS) seldom occurs isolated but is usually combined with CECS of the anterior (ant-CECS) or deep posterior compartment (dp-CECS). Patient characteristics in lat-CECS and outcome after surgery are largely unknown. The aim of this prospective case series was to describe patient characteristics and symptoms and to report on outcome following a fasciotomy., Methods: All patients diagnosed with lat-CECS based on exertional lateral lower leg symptoms and elevated intracompartmental pressure (ICP) measurements according to the Pedowitz criteria (ICP ≥ 15 mm Hg at rest, and/or ≥30 mm Hg after 1 minute, and/or ≥20 mm Hg 5 minutes after exercise) were eligible for this study. A standard intake questionnaire scoring symptom patterns was completed by all patients. Patients who were operated for lat-CECS were asked to complete a 3-month and 12-month postoperative questionnaire scoring symptoms and surgical outcome. Patients with a history of CECS surgery, recent lower leg trauma, or peripheral neurovascular disease were excluded., Results: A total of 881 patients with possible lower leg CECS completed an intake questionnaire and 88 (10%) were diagnosed with lat-CECS according to the Pedowitz criteria (isolated lat-CECS n = 10; lat/ant CECS n = 54, lat/ant/dp CECS n = 19, lat/dp CECS n = 5). Severe pain during exercise and moderate tightness during rest were frequently reported. A group of 28 patients (49 legs; isolated lat-CECS n = 2; lat/ant CECS n = 22, lat/ant/dp CECS n = 3, lat/dp CECS n = 1) was analyzed after fasciotomy. Complications were minor (wound infection requiring antibiotics, n = 3; temporary complex regional pain syndrome with spontaneous recovery, n = 1). Superficial peroneal nerve damage was not observed. One year after surgery, 64% rated outcome as excellent or good, whereas 71% had resumed sports activities., Conclusion: One in 10 patients with anterolateral exertional lower leg pain evaluated in a tertiary referral center met diagnostic criteria for lat-CECS. Pain and tightness were present during exertion and were often reported occurring during rest and at night. In this series, we found fasciotomy-either an isolated (lateral) or a multiple (combined with anterior and/or deep posterior) compartment fasciotomy-is safe and beneficial in most patients., Level of Evidence: Level IV, case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Although patients with lumbar disc herniation (LDH) can achieve significant relief from lower back and leg pain after lumbar microdiscectomy, a few patients complain of discomfort due to residual leg numbness (RLN). This study aimed to identify potential risk factors for RLN after lumbar microdiscectomy. We prospectively collected and analyzed patients with LDH who underwent microdiscectomy between September 2016 and December 2020. All included patients had preoperative LN symptoms. Patients with RLN were defined as those with LN at the last follow-up. The relationships between RLN and sex, age, body mass index (BMI), current smoking status, diabetes mellitus, revision surgery, preoperative LN Numeric Rating Scale (NRS) score, duration of preoperative LN, RLN at discharge, sagittal range of motion (SROM), Modic change, disc Pfirrmann grade were analyzed. The RLN was observed in 33.5% (112/334) of patients at the last follow-up. No significant differences were observed in age, sex, BMI, current smoking status, or diabetes between the RLN and non-RLN groups. The preoperative LN NRS score, preoperative LN duration, rate of RLN at discharge, and revision surgery were significantly higher in the RLN group than those in the non-RLN group. Multivariate logistic regression analysis identified the preoperative LN NRS score, duration of preoperative LN, RLN at discharge, revision surgery, and SROM as risk factors for RLN in the long-term follow-up. Patients with higher preoperative LN NRS scores and SROM, longer preoperative LN duration, RLN at discharge, and revision surgery were more likely to experience RNL after lumbar microdiscectomy., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Purpose: Accurate measuring tools are essential in preoperative planning and for the study of the association between postoperative alignment and clinical outcome in total knee arthroplasty (TKA). We aimed to describe a simple method to measure preoperative hip-knee-femoral shaft (HKFS) angle and postoperative coronal alignment in TKA with the use of standard 3D CT and to compare preoperative HKFS angles and postoperative coronal alignment measured with the 3D CT technique and with standing long-leg hip-knee-ankle (HKA) radiographs., Patients and Methods: HKA radiographs and 3D CT were taken preoperatively and 3 months after the operation in 121 knees. The interrater reliability for the 3D CT method was calculated with intra-class correlation coefficient (ICC). The preoperative HKFS angles and the postoperative deformity measured with the 2 methods were compared and illustrated on Bland-Altman plots, frequency tables, and by Cohen's kappa coefficients (k)., Results: The 3D CT method was feasible in all knees and the ICC was excellent. Mean (SD, range) difference in HKFS angle measured on HKA radiographs and on 3D CT was -0.3° (0.9°, -4.1° to 2.4°). Mean (SD, range) difference in postoperative deformity was 0.1° (1.6°, -5° to 6°). The 95% limits of agreement were 1.4° and -2° for HKFS and ±3° for postoperative alignment. The agreement in outlier (≥ 3°) identification was moderate with a k (95% confidence interval) of 0.48 (0.32-0.64)., Conclusion: 3-dimensional computer tomography was feasible and was shown to be more accurate than traditional long-leg radiographs.

Objective: To explore the effects of low position lateral supramalleolar flap carrying periosteum and proximal leg propeller flap in relay repair of electric burn wounds of forefoot. Methods: A retrospective observational study was conducted. From January 2019 to January 2022, 12 patients with electric burn wounds of forefoot meeting the inclusion criteria were admitted to the Sixth Hospital of Shanxi Medical University, including 10 males and 2 females, aged 23-65 years. After debridement, the wound with an area of 6.0 cm×3.0 cm to 15.0 cm×7.0 cm was repaired with the lateral supramalleolar flap carrying part of the periosteum of the distal tibia and fibula with the rotation point moved down to the front of the ankle joint. The area of the cutted flap was 6.5 cm×3.5 cm-15.5 cm×7.5 cm. At the same stage, the donor site wound of lateral supramalleolar flap was repaired with peroneal artery or superficial peroneal artery perforator propeller flap in relay, with the relay flap area of 3.0 cm×1.5 cm-15.0 cm×4.0 cm. After operation, the survival of the lateral supramalleolar flap and relay flap, and the wound healing of the relay flap donor site were observed. During follow-up, the shapes of the lateral supramalleolar flap and its donor site were observed. Results: After operation, one patient developed secondary blisters in the superficial skin distal to the lateral supramalleolar flap, which healed after dressing change, and the lateral supramalleolar flap and relay flaps survived well in the other patients; the donor site wound of the relay flap healed well. During follow-up of 12-18 months, the lateral supramalleolar flaps were in good shape and not bloated, with only linear scar left in the donor site of the flap. Conclusions: The low position lateral supramalleolar flap carrying periosteum can repair electric burn wounds of forefoot with advantages including reliable blood supply, low rotation point, and better repair effects. The use of relay flap to repair the donor site of lateral supramalleolar flap can reduce the damage to the appearance and function of the donor site.

Introduction: We report a case of a serious traffic accident injury to the lower leg involving a large skin defect with the long bone exposed. In this situation, the usual intervention is flap transplantation after debridement and infection control by completely covering the wound. Flap transplantation has certain limitations; therefore, we chose the surgical strategy of cortical bone drilling-induced membrane technology (Masquelet technique)., Case Presentation: A 28-year-old healthy man was injured in a car accident and presented to the local hospital with a large skin defect and exposed left lower leg long bone. After transfer to our hospital, the patient underwent repeated debridement and skin graft, a cortex borehole combined with bone cement cover, and ankle fusion. The patient achieved full recovery., Conclusion: From our experience in treating this case, we conclude that large skin defects, periosteal stripping, and bone exposure due to physical injury can be successfully treated with cortical perforation and the Masquelet technique so as to avoid flap transplantation. Therefore, this method can be used for large segment bone exposure., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

While previous studies on navigated total hip replacement (nTHA) focused on acetabular component positioning, we compared the results of nTHA with conventional total hip replacement (cTHA) in respect of changes in leg length and hip offset. In a single-center study results radiographic parameters of patients with unilateral THA were included. Data were retrospectively analyzed from computer navigation data and radiographs. Analysis concentrated on the discrepancy in leg length (LLD) and hip offset (OSD) between the affected and unaffected hip. The effect of the procedure was defined as the difference between postoperative and preoperative LLD and OSD values in each group. 2332 patients were analyzed. Both nTHA and cTHA were effective in restoring LLD and OSD by reducing the preoperative value significantly (p < 0.001). Regarding changes in LLD, no statistical difference between nTHA and cTHA could be found. Changes in OSD nTHA was a slightly more effective than cTHA (- 2.06 ± 6.00 mm vs. - 1.50 ± 5.35 mm; p < 0.05). Both navigated and conventional THA were successful in reconstruction of leg length and hip offset, while postoperative offset discrepancy was significantly lower in the navigated group at the cost of longer operation times. If these results are clinically relevant further investigation is needed., (© 2023. Springer Nature Limited.)

Background: Leg-length discrepancy (LLD) is a critical factor in component selection and placement for total hip arthroplasty. However, LLD radiographic measurements are subject to variation based on the femoral/pelvic landmarks chosen. This study leveraged deep learning (DL) to automate LLD measurements on pelvis radiographs and compared LLD based on several anatomically distinct landmarks., Methods: Patients who had baseline anteroposterior pelvis radiographs from the Osteoarthritis Initiative were included. A DL algorithm was created to identify LLD-relevant landmarks (ie, teardrop (TD), obturator foramen, ischial tuberosity, greater and lesser trochanters) and measure LLD accurately using six landmark combinations. The algorithm was then applied to automate LLD measurements in the entire cohort of patients. Interclass correlation coefficients (ICC) were calculated to assess agreement between different LLD methods., Results: The DL algorithm measurements were first validated in an independent cohort for all six LLD methods (ICC = 0.73-0.98). Images from 3,689 patients (22,134 LLD measurements) were measured in 133 minutes. When using the TD and lesser trochanter landmarks as the standard LLD method, only measuring LLD using the TD and greater trochanter conferred acceptable agreement (ICC = 0.72). When comparing all six LLD methods for agreement, no combination had an ICC>0.90. Only two (13%) combinations had an ICC>0.75 and eight (53%) combinations had a poor ICC (<0.50)., Conclusion: We leveraged DL to automate LLD measurements in a large patient cohort and found considerable variation in LLD based on the pelvic/femoral landmark selection. This emphasizes the need for the standardization of landmarks for both research and surgical planning., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Arthroscopic lateral meniscus repair is performed in the "figure-of-4 position" (supine, with the affected knee flexed and the lower leg crossed over the extended contralateral leg), and anchorage is often on the popliteal tendon. Extending the limb at the end of the procedure alters the relations between the popliteal tendon and the repaired meniscus. The present study aimed to assess lateral meniscal suture fixation on the popliteal tendon after a cycle of flexion-extension., Hypothesis: Extending the knee can induce suture release., Type of Study: Cadaver study., Materials and Methods: Twenty-two fresh adult human cadaver knee specimens were used. Under arthroscopy with all-inside implants, a vertical suture onto the popliteal tendon was performed through the lateral meniscus. Suture status was assessed under arthroscopy after a cycle of flexion-extension, and deemed defective if the suture was sufficiently loose for the arthroscope to be able to be passed through the popliteal hiatus, if the stitch had passed through the meniscus, or if the suture was broken., Results: Thirteen sutures (59.1%) remained well fixed, and 9 (40.1%) were defective: 4 (18.2%) were loose, in 4 (18.2%) the stitch had passed through the meniscus, and in 1 (4.5%) the suture had broken., Conclusion: In a population of elderly cadaver knee specimens, arthroscopic suture of the lateral meniscus to the popliteal tendon was defective after flexion-extension in 40% of cases. Stress seems to be exerted on the suture when extension is resumed. Thus, a single stitch seems insufficient for stable lateral meniscus repair., Clinical Implications: Suture of the lateral meniscus to the popliteal tendon undergoes stress when extension is resumed, potentially causing failure of lateral meniscus repair., Level of Evidence: IV., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Lymphedema is a chronic edema that sometimes occurs after treatment of gynecologic cancer, and cellulitis often occurs concomitantly with lymphedema. On the other hand, necrotizing fasciitis (NF) is a relatively rare, but life-threatening disease. The symptoms in cellulitis and NF are very similar. In this case report, we describe a case in which the diagnosis of NF in a lymphedematous limb was difficult. A 70-year-old woman had secondary lymphedema in bilateral legs and consulted our department. On the first day of lymphedema therapy, the patient complained of vomiting, diarrhea, and fever (37.7 °C) without local fever in the legs. She was diagnosed with acute gastroenteritis. On the next day, swelling and pain in her left leg occurred and her blood pressure was 59/44 mmHg. She was diagnosed with cellulitis accompanied by lower limb lymphedema and septic shock. On the second day, blisters appeared on the left leg, and computed tomography showed NF. We performed debridement under general anesthesia and her vital signs improved postoperatively. Streptococcus agalactiae (B) was detected in blood culture, and we administered bixillin and clindamycin. Postoperatively, necrosis in the skin and fat around the left ankle gradually spread, and it took 5 months to complete epithelialization. The diagnosis was more difficult than usual NF because patients with lymphedema often experience cellulitis. Clinicians should always think of NF to avoid mortality due to delayed treatment. This case report was approved by the institutional ethics committee.

For paediatric orthopaedic surgeons treating leg length discrepancy, knowledge of the available procedures and their options and limits is just as important as mastery of the very different surgical methods and implants, as well as the possible complications, in order to be able to advise and treat the children and adolescents and their parents comprehensively and in the best interests. Both the growth inhibiting procedures and the complex bone lengthening procedures require a great deal of experience to successfully guide patients and families through what is often a lengthy and sometimes complicated treatment process. Careful preoperative indications and planning, precise surgical techniques with suitable instruments and implants, and attentive postoperative check-ups are mandatory prerequisites for the desired therapeutic success., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Background: Lower limb malrotations can be observed in long leg radiographs, affecting the measurement of the angle between the mechanical and anatomical axes. The purposes were to analyze the effect of limb rotation and to evaluate the accuracy of the corrected angle between the mechanical and anatomical axes based on the patellar ML position., Hypothesis: The hypothesis was that the correction of the angle between the mechanical and anatomical axes according to the patellar ML position can reduce the error from the angle in the true AP view in most of the knees., Patients and Methods: A total of 100 consecutive knees with varus deformity undergoing primary total knee arthroplasty were included. Computed tomography images were digitally reconstructed in the neutral position, and internally and externally rotated at 10° and 20°, respectively. The patellar ML position relative to the medial (0%) and lateral (100%) epicondyles and the angle between the mechanical and anatomical axes of the femur were measured. The corrected angle between the mechanical and anatomical axes was calculated using the averaged translational ratio., Results: In the neutral position, the patellar center position was 56.1% (standard deviation [SD]=4.7%), which was 31.4% (SD=7.2%) and 80.2% (SD=5.4%) in the 20° internal and external rotation, respectively. The angle between the mechanical and anatomical axes was 2.6° (SD=2.0°) and 8.1° (SD=2.1°) in the 20° internal and external rotation, respectively. On average, if the patellar center shifted 10%, the change of the angle between the mechanical and anatomical axes of the femur was 1.13°. Applying the corrected angle, a discrepancy from the neutral position decreased., Conclusion: The method to correct the angle between the mechanical and anatomical axes according to the patellar ML position can be used to reduce the measurement error for preoperative planning using a long leg radiograph., Level of Evidence: III., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: THA for high-riding developmental dysplasia of the hip (DDH) is challenging in terms of length equalization. Although previous studies suggested preoperative templating on AP pelvic radiographs is insufficient in patients with unilateral high-riding DDH because of hypoplasia of the hemipelvis on the affected side and unequal femoral and tibial length on scanograms, the results were controversial. The EOS™ (EOS™ Imaging) is a biplane X-ray imaging system using slot-scanning technology. Length and alignment measurements have been shown to be accurate. We used the EOS to compare the lower limb length and alignment in patients with unilateral high-riding DDH., Questions/purposes: (1) Is there an overall leg length difference in patients with unilateral Crowe Type IV hip dysplasia? (2) In patients with unilateral Crowe Type IV hip dysplasia with an overall leg length difference, is there a consistent pattern of abnormalities in the femur or tibia that account for observed differences? (3) What is the impact of unilateral high-riding Crowe Type IV dysplasia on femoral neck offset and knee coronal alignment?, Methods: Between March 2018 and April 2021, we treated 61 patients with THA for Crowe Type IV DDH (high-riding dislocation). EOS imaging was performed preoperatively in all patients. Eighteen percent (11 of 61) of the patients were excluded because of involvement of the opposite hip, 3% (two of 61) were excluded for neuromuscular involvement, and 13% (eight of 61) had previous surgery or fracture, leaving 40 patients for analysis in this prospective, cross-sectional study. Each patient's demographic, clinical, and radiographic information was collected with a checklist using charts, Picture Archiving and Communication System, and an EOS database. EOS-related measurements that were related to the proximal femur, limb length, and knee-related angles were recorded for both sides by two examiners. The findings of the two sides were statistically compared., Results: The overall limb length was not different between the dislocated and nondislocated sides (mean 725 ± 40 mm versus 722 ± 45 mm, mean difference 3 mm [95% CI -3 to 9 mm); p = 0.08). Apparent leg length was shorter on the dislocated side (mean 742 ± 44 mm versus 767 ± 52 mm, mean difference -25 mm [95% CI -32 to 3 mm]; p < 0.001). We observed that a longer tibia on the dislocated side was the only consistent pattern (mean 338 ± 19 mm versus 335 ± 20 mm, mean difference 4 [95% CI 2 to 6 mm]; p = 0.002), but there was no difference between the femur length (mean 346 ± 21 mm versus 343 ± 19 mm, mean difference 3 mm [95% CI -1 to 7]; p = 0.10). The femur of the dislocated side was longer by greater than 5 mm in 40% (16 of 40) of patients and shorter in 20% (eight of 40). The mean femoral neck offset of the involved side was shorter than that of the normal side (mean 28 ± 8 mm versus 39 ± 8 mm, mean difference -11 mm [95% CI -14 to -8 mm]; p < 0.001). There was a higher valgus alignment of the knee on the dislocated side with a decreased lateral distal femoral angle (mean 84° ± 3° versus 89° ± 3°, mean difference - 5° [95% CI -6° to -4°]; p < 0.001) and increased medial proximal tibia angle (mean 89° ± 3° versus 87° ± 3°, mean difference 1° [95% CI 0° to 2°]; p = 0.04)., Conclusion: A consistent pattern of anatomic alteration on the contralateral side does not exist in Crowe Type IV hips except for the length of the tibia. All parameters of the limb length could be shorter, equal to, or longer on the dislocated side. Given this unpredictability, AP pelvis radiographs are not sufficient for preoperative planning, and individualized preoperative planning using full-length images of the lower limbs should be performed before arthroplasty in Crowe Type IV hips., Level of Evidence: Level I, prognostic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background:  One of the most challenging yet common areas in reconstructive surgery is the closure of defects in the lower leg. Surgeons can choose from several reconstructive options including local and free flaps. The aim of this study was to understand the reconstructive strategy for lower leg defects of different microsurgeons around the world by harnessing the power of social media and online questionnaires., Methods:  A case of a patient with an exposed plate over distal tibial fracture was presented via an online questionnaire distributed on various social media platforms. A total of 369 international microsurgeons replied with their preferred treatment choice. The data were analyzed according to geographic area, microsurgical training, seniority, and subspecialty., Results:  Among all the respondents ( n  = 369), 64% would have opted for a free flap reconstruction, while the remaining 36% would have opted for a local/pedicle flap. In the group that would have opted for a free flap, 63% would reconstruct the defect using a free fasciocutaneous flap, while the remaining 37% would have used a free muscle flap. In the local flap group, 60% would have used a local perforator while 30% would have chosen a conventional local flap. While North American and European microsurgeons had a clear preference toward free flaps, Asian, Middle Eastern, African, and South American surgeons were evenly divided between local and free flaps., Conclusion:  In this study, we provide a current global overview of the reconstructive strategies for a lower limb with skin defect and bone or prosthesis exposure. We hope that this will be able to help global microsurgeons and patients worldwide., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To investigate the effects of tibial second toe free flap bridged with blood flow and nerve in the treatment of severe flexion contracture of the proximal interphalangeal joint. Methods: A retrospective observational study was conducted. From March 2013 to October 2019, 9 patients with severe flexion contracture (type Ⅲ) of the proximal interphalangeal joint after trauma operation, conforming to the inclusion criteria, were hospitalized in Suzhou Ruihua Orthopaedic Hospital, including 5 males and 4 females, aged from 17 to 62 years. After the contracture tissue affecting the extension of the proximal interphalangeal joint was cut off, and the scar tissue was resected, the size of the volar wound near the proximal interphalangeal joint in extended position was 2.0 cm×1.0 cm-2.5 cm×1.5 cm, with the length of proper digital artery and nerve defect being 1.0-1.5 cm. A free flap of the same size as the wound was cut from the tibial side of the second toe and transplanted to repair the wound, and the defective proper digital artery and nerve was repaired by bridging with the tibial proper plantar digital artery and nerve of about 1.5 cm in length. The full-thickness skin graft was taken from the proximal tibial side of the lower leg to repair the wound at flap donor site. The wound at skin graft donor site was sutured directly. The survival of flap and skin graft was observed after operation. The patients were followed up, and at the last follow-up, the recovery of the affected finger and the second toe, including the donor and recipient areas were observed, the two-point discrimination distances of the flap repaired site and the pulp of the affected finger were observed and measured at the same time, the blood flow patency of bridged vessel of the affected finger was examined by Allen test, and the function of the proximal interphalangeal joint of the affected finger was evaluated according to Chinese Medical Association's standard for the range of motion of proximal interphalangeal joint. Results: The flaps and skin grafts survived smoothly after operation. The follow-up after operation lasted for 5 to 22 months, with a mean of 10 months. At the last follow-up, the flap repaired site had good shape, good color and texture, with the two-point discrimination distance being 9-12 mm, and the two-point discrimination distance of the pulp of the affected finger was 6-10 mm; the Allen test results of the affected fingers were all negative (i.e., the bridged vessels had good blood flow patency), with no recurrence of flexion contracture, and the function of the proximal interphalangeal joint was evaluated as excellent; the skin graft area of the second toe was not ruptured but was a little pigmented, and the flexion and extension activities of toe were good. Conclusions: The tibial second toe free flap bridged with blood flow and nerve has reliable therapeutic effect in the treatment of severe flexion contracture of the proximal interphalangeal joint, and the color and texture of the flap repaired area are good. Bridging to repair the severely contracted proper digital artery and nerve is beneficial to improve the blood supply of the finger body and rebuild the sensation.

Leg-length discrepancy (LLD) presents a significant management challenge to orthopedic surgeons and remains a leading cause of patient dissatisfaction and litigation after total hip arthroplasty (THA). Over or under-lengthening of the operative extremity has been shown to have inferior outcomes, such as dislocation, exacerbation of back pain and sciatica, and general dissatisfaction postoperatively. The management of LLD in the setting of THA is multifactorial, and must be taken into consideration in the pre-operative, intra-operative, and post-operative settings. In our review, we aim to summarize the best available practices and techniques for minimizing LLD through each of these phases of care. Pre-operatively, we provide an overview of the appropriate radiographic studies to be obtained and their interpretation, as well as considerations to be made when templating. Intra-operatively, we discuss several techniques for the assessment of limb length in real time, and post-operatively, we discuss both operative and non-operative management of LLD. By providing a summary of the best available practices and strategies for mitigating the impact of a perceived LLD in the setting of THA, we hope to maximize the potential for an excellent surgical and clinical outcome., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Reconstruction of defects around the knee and proximal leg are difficult to reconstruct. Out of the multiple flaps described for reconstruction, the pedicled Medial Sural Artery Perforating Flap (MSAP) has recently gained popularity. We conducted this study to assess the clinical outcomes of pedicled MSAP for this purpose at our hospital., Methods: A descriptive case series was conducted from April 2022 to March 2023. All patients above 18 years with defects around the knee and proximal leg were included. Patients with tissue loss in the calf area were excluded., Results: A total of 14 patients were included. Twelve (86%) were males, while only 2 were females (14%). The mean age was 33.5 years (±8.76). The most common cause of the defect was trauma (n=11, 85%). The Mean distance of the distal-most perforator from the popliteal crease was 12.714 (±1.990) cm (range 9-16 cm). It was observed that the most distal perforator is usually present in a 2 cm radius of the medial musculo-tendinous junction of the gastrocnemius. Complications were seen in 2 (14%) patients. The mean duration of hospital stay was 4.2 (±0.96) days. Patients were followed up weekly for the first two weeks and then at 1, 3 and 6 months., Conclusions: MSAP Flap is a reliable thin, long pedicled fasciocutaneous flap with low donor site morbidity and aesthetically good results for reconstruction around the knee and proximal leg.

Background: The decision between local and free tissue coverage for distal lower leg defects has long been dictated by the location and size of defects. Recent reports of distal defects treated successfully with pedicled perforator flaps demonstrate equivalent clinical outcomes; however, the complication rate can be high. The goal of this study was to evaluate the cost equivalence of free versus pedicled perforator flap to assist decision-making and guide clinical care., Methods: The institutional database was searched for patients with acute injury over the distal lower extremity requiring free or pedicled perforator flap. Demographic, clinical, and total resource cost was gathered. Patients were matched to Gustilo-Anderson or Arbeitsgemeinschaft fur Osteosynthesefragen classification as well as size of defect and outcomes, and cost compared., Results: We have included 108 free flaps and 22 pedicled perforator flaps in the study. There was no difference in complication rate between groups. Free flaps had significantly more reoperations, required longer operative time, and had longer intensive care unit (ICU) care with higher cost of surgery and overall cost than pedicled flaps. When controlling for size of defect, surgical cost remained significantly different between groups ( p  = 0.013), but overall cost did not. Multivariable regression analysis indicated flap type to be the primary driver of cost of surgery, while body mass index elevated the total cost., Conclusion: Pedicled perforator flap coverage for small to medium-sized defects (< 70 cm 2 ) is a viable and cost-effective option for distal lower leg soft tissue reconstruction after acute traumatic injury with similar clinical outcomes and shorter operative duration and ICU stay., Competing Interests: None declared., (Thieme. All rights reserved.)

The results of treatment of 36 patients with extensive gunshot defects on the foot and lower leg with the use of a neurovascularized flap on the sural artery have been analyzed. Goal - to investigate the effect of catheterization of the small saphenous vein, which is included in the flap, on the frequency of development of its ischemic complications. The 1st group (n=14) included the wounded, who underwent complex treatment of an extensive gunshot defect followed by its plasticity with a "sural flap" with temporary catheterization of the small subcutaneous vein included in its composition. The 2nd group (n=23) included patients who, after complex treatment of an extensive gunshot defect, underwent plastic surgery with a "sural flap" without catheterization of the vessels included in it. In case of using a flap without catheterization of the small saphenous vein, necrosis of the "sural" flap was observed in 5 (22%) cases. During catheterization of the small saphenous vein, the number of flap necrosis was 2 (15%) cases. Catheterization of the small saphenous vein of the "sural" flap allows to reduce the frequency of complications related to blood supply disorders by 7%.

Background: Only few studies have been conducted on leg length discrepancy (LLD) in patients with hip osteoarthritis (OA). This study aimed to examine the relationship between perceived LLD (pLLD) and structural LLD (sLLD) in patients with advanced OA and to determine the factors influencing both LLDs. This retrospective study aimed to answer the following questions: (1) are older adults less likely to perceive LLD than younger adults? (2) is there a relationship between pLLD and sLLD? and (3) is pLLD associated with patient satisfaction?, Hypothesis: We hypothesized that older adults are less likely to perceive LLD than younger adults., Patients and Methods: We recruited 125 patients (102 women and 23 men) with hip OA associated with developmental dysplasia of the hip defined as grade 3 or higher according to the Tönnis classification and excluding contralateral grade 2 or higher. The mean age of the patients was 65.2±11.2 (36-85) years. Before surgery, 2-mm and 5-mm thick plates were placed on the floor on the plantar surface of the short leg to measure pLLD. Preoperative computed tomography (CT) was performed and sLLDs were measured using the 3D planning software ZedHip. The following associated factors were evaluated: age, height, weight, body mass index (BMI), adduction and abduction range of motion (ROM) of the affected hip joint, Crowe classification, standing pelvic inclination in the coronal plane, Cobb angle and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ)., Results: The absolute difference between pLLD and sLLD was modestly positively correlated with age (R=0.206; p<0.05) indicating older patients were less prone to perceive LLD. A strong positive correlation was found between pLLD (4.8±7.3mm; range: -37 to 28mm) and sLLD (6.4±7.0mm; range: -29.9 to 23.7mm) (R=0.714, p<0.05). The greater the pLLD, the smaller the hip abduction ROM (24.8±11.6°; range: 0 to 45°) tended to be, while the greater the sLLD, the smaller the hip abduction and adduction ROM (10.3±5.7°; range: 0 to 25°) tended to be (R= -0.259 and R= -0.297, respectively; p<0.05) The clinical significance of this finding is that pLLD may be improved if hip ROM training is performed before surgery. pLLD was significantly smaller in the group without pelvic inclination (8.0±14.1mm; range: -37 to 22mm) than in the group with pelvic inclination to the affected side (6.9±7.5mm; range: -12 to 28mm) and in the group with no inclination to the affected side (7.3±7.6mm; range: -8 to 25mm) (p<0.05) The clinical significance of this finding is that improving pelvic inclination with hip ROM training or muscle stretching may also reduce pLLD. No significant differences were noted between pLLD and JHEQ total scores or subgroups., Discussion: Older patients had less pLLD. Preoperative pLLD was strongly correlated with sLLD but not with patient satisfaction. These results may be useful for conservative treatment of OA, preoperative planning and intraoperative leg length correction., Level of Evidence: IV; case control study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Improper alignment and implant positioning following unicompartmental knee arthroplasty (UKA) has been shown to lead to postoperative pain and increase the incidence of revision procedures. The use of robotic-arm assistance for UKA (RAUKA) has become an area of interest to help overcome these challenges. The accuracy of intraoperative alignment compared with standing long-leg X-rays postoperatively following medial RAUKA has been in question. Therefore, the purpose of this study was to (1) determine final mean intraoperative coronal alignment in extension utilizing an image based intraoperative navigation system, and (2) compare final intraoperative alignment to 6-week weight-bearing (WB) long-leg X-rays. Patients who underwent RAUKA for medial compartmental osteoarthritis were identified from January 1, 2018, to August 31, 2019, through our institution's joint registry. The query yielded 136 (72 right and 64 left) patients with a mean age of 72.02 years and mean body mass index (BMI) of 28.65 kg/m 2 who underwent RAUKA. Final intraoperative alignment was compared with WB long leg X-rays 6 weeks postoperatively by measuring the mechanical alignment. Statistical analysis was primarily descriptive. Pearson's correlation coefficient was used to determine the relationship between intraoperative alignment to 6-week alignment. A p- value of <0.05 was considered statistically significant. Mean intraoperative coronal alignment after resections and trialing was 4.39 varus ± 2.40 degrees for the right knee, and 4.81 varus ± 2.29 degrees for the left knee. WB long-leg X-rays 6 weeks postoperatively demonstrated mechanical axis alignment for the right and left knees to be 3.01 varus ± 2.10 and 3.7 varus ± 2.38 degrees, respectively. This resulted in a change in alignment of 1.36 ± 1.76 and 1.12 ± 1.84 degrees for the right and left knees, respectively ( p   <  0.05). Pearson's correlation coefficient demonstrated a correlation of 0.69 between intraoperative to long-leg-X-ray alignment. RAUKA demonstrates excellent consistency when comparing postoperative WB long-leg X-rays to final intraoperative image-based non-WB alignment., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: During total hip arthroplasty (THA), both pelvic and femur positions affect leg length (LL) and offset (OS) measurements because LL and OS calipers depend on the fixed reference points on the pelvis and femur, respectively. However, LL and OS measurement errors because of pelvic positional changes have not been described. This study aimed to clarify the effects of pelvic positional changes on LL and OS measurements in relation to the pelvic reference using a THA simulator., Methods: We developed an experimental THA simulator using Sawbones models of the hemipelvis and femur that facilitated modification of the obliquity, tilt, and rotation of the pelvis. Using an LL and OS caliper, LL and OS measurement errors due to pelvic positional changes were determined with the femoral position fixed. Measurements were performed from two pelvic reference positions: the iliac tubercle (P1) and the top of the iliac crest intersecting the line of the femoral long axis (P2)., Results: Concerning pelvic obliquity, the total error of LL was 25.0 mm in P1 and 26.5 mm in P2, while the total error of OS was 13.0 mm in P1 and 10.9 mm in P2. For pelvic tilt, the total error of LL was 9.0 mm in P1 and 3.8 mm in P2, while the total error of OS was 0.5 mm in P1 and 1.0 mm in P2. Regarding pelvic rotation, the total error of LL was 13.8 mm in P1 and 3.2 mm in P2, while the total error of OS was 3.8 mm in P1 and 4.0 mm in P2., Conclusions: Pelvic positional changes alter LL and OS measurements. The acceptable range (error <2 mm) on LL and OS measurement errors of pelvic obliquity was only 2°, regardless of the pelvic reference position. The pelvic reference position should be at the top of the iliac crest intersecting the line of the long axis of the femur because of a small LL measurement error with pelvic tilt and rotation., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: To explore the clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery. Methods: A retrospective observational study was conducted. From January 2019 to June 2021, 12 patients with wounds after lower leg limb-sparing surgery who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 6 males and 6 females, aged 17 to 74 years, with original wound area ranging from 17 cm×9 cm to 40 cm×15 cm. Five patients had infection in wounds. The wounds were all repaired by free anterolateral thigh perforator flap from contralateral thigh, with area of 18 cm×10 cm to 37 cm×9 cm. The artery of flap was anastomosed with the descending genicular artery, and the wounds in donor areas were sutured directly. Seven patients were transplanted with split-thickness skin grafts from the contralateral thigh to cover the remaining wounds that can not be covered by flap and the wounds in donor areas were covered with gauze. During the operation, the types of perforating branch carried by flap and the types of arteries and veins in recipient areas were recorded. The survival and occurrence of vascular crisis of flap, the survival of skin graft, the wound healing in donor and recipient areas, and the length of hospital stay after flap transplant surgery were recorded. During follow-up, the color and texture of flap, reinfection in lower leg, and fracture healing were recorded. At the last follow-up, the limb salvage function of patients was evaluated according to the functional evaluation criteria of Chen Zhongwei's amputated limb replantation. Results: The types of perforating branches carried by flaps were as follows: 6 cases of only carrying the descending branch of the lateral circumflex femoral artery, 3 cases of only carrying the oblique branch of the lateral circumflex femoral artery, and 3 cases of carrying the descending branch of the lateral circumflex femoral artery and oblique branch of the lateral circumflex femoral artery after internal pressurization anastomosis. The types of arteries in the recipient area of flap were as follows: one case of main trunk of the descending genicular artery, 8 cases of the saphenous branch of the descending genicular artery, and 3 cases of the articular branch of the descending genicular artery. The types of veins in the recipient area of flap were as follows: 8 cases of one accompanying vein of the descending genicular artery and one branch of the great saphenous vein, and 4 cases of two branches of the great saphenous vein. All the flaps survived without vascular crisis, and all the skin grafts also survived. The wounds in the donor and recipient areas were all healed. The length of hospital stay of patient after flap transplant surgery ranged from 13 to 79 days. During the follow-up of 6 to 23 months, the color and texture of flap were both good, with no infection in lower leg wound. Internal or external fixation were removed after fracture healing in 5 patients, and bone graft internal fixation was performed in 7 patients whose fractures were not healed after surgery and all the incisions healed without infection. At the last follow-up, the limb salvage effect of patients was evaluated as followings: excellent in 7 patients, good in 4 patients, and fair in one patient. Conclusions: Free anterolateral thigh flap pedicled with descending genicular artery can effectively repair the wounds after lower leg limb-sparing surgery and control infection with short length of hospital stay, while not increasing the risk of secondary injury of distal limb vessels. Thus, it can obtain satisfactory limb salvage effect which is worthy of clinical promotion.

Rationale: The RoboticScope (BHS Technologies GmbH, Innsbruck, Austria) is a robotic exoscope, which consists of a robotic arm that holds a 3-dimensional camera. It has an advantage that a surgeon can perform an operation comfortably with a favorable ergonomic position. Also, it allows the delivery of clear and high-quality visualization for surgeons. In this study, we would like to share our initial experience with this newly developed microscope technology in lymphaticovenular anastomosis (LVA). To the best of our knowledge, it is the first experience of LVA using this microscope in Asia., Patient Concerns: A 65-year-old woman presented with bilateral lower extremity lymphedema after a hysterectomy that was performed 25 years back. Despite complex decongestive physiotherapy, an edematous symptom in both legs worsened., Diagnoses: In lymphoscintigraphy, a decreased visualization of main lymphatic flow in both the lower extremities was evident which was further suggestive of lymphatic obstruction., Intervention: Although both sides showed edematous symptoms, we decided to proceed with the surgery on the left side first, because of the worsened condition. Four LVAs were performed at the dorsum of the foot (×2), ankle, and the superior edge of the knee using RoboticScope., Outcomes: At 6-months follow-up after operation, the postoperative circumference diameters were improved than preoperative in 10 cm above the knee (45 cm vs 49 cm), 10cm below the knee (37 cm vs 41 cm) and lateral malleolus (25 cm vs 28 cm). The lower extremity lymphedema index was also improved from 346.7 to 287.4 postoperatively. The RoboticScope provided a high-resolution image and a favorable ergonomic position during an operation., Lessons: The results represent the possibility of the application of a robotic microscope in the field of microsurgery, and further studies are necessitated to confirm the efficacy of this system., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: The leg length discrepancy (LLD) in the supine decubitus position may influence the inclination angle of the acetabular component during total hip arthroplasty (THA). The relationship among LLD, pelvic obliquity, and inclination angle of the acetabular component has not been well studied. This study aimed to evaluate the relationship between LLD in supine position and changes in the inclination angle of the acetabular components during THA, and the compensatory ability of the pelvis based on LLD and inclination., Methods: A total of 135 patients were prospectively classified into three groups according to the preoperative LLD in the supine decubitus position: the cranial type group had a positive LLD value; the fixed type group had LLD = 0; and the caudal type group had a negative LLD value. Patients in the cranial type group and caudal type group were divided into four subgroups based on the LLD value (either positive or negative): LLD >3 cm subgroup; 2 ≤ LLD ≤ 3 cm subgroup; 1 ≤ LLD < 2 cm subgroup; and LLD <1 cm subgroup. The targeted and final inclination of the acetabular component was measured intra- and postoperatively., Results: The results showed a significant difference in the targeted and final inclination angles among the patients in the cranial type and the caudal type groups. In the caudal type group, increased inclination was observed in the patients of LLD >3 cm subgroup (mean 3.13°) and 2 ≤ LLD ≤ 3 cm subgroup (mean 5.17°) after THA, respectively. Decreased inclination (mean, 6.16°) was observed in 2 ≤ LLD ≤ 3 cm subgroup in the cranial type group after THA., Conclusions: Our findings revealed that in patients with discrepancy greater than 2 cm, postural pelvic obliquity imposed a remarkable influence on the inclination., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)