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Evolving Patient Perception of Limb Length Discrepancy Following Total Hip Arthroplasty
Abstract
Background
Limb length discrepancy (LLD) is a known complication of total hip arthroplasty (THA), leading to decreased patient function and satisfaction. It remains unknown how a patient’s perception of LLD evolves over time. The aim of this study was to evaluate the relationship between measured and perceived LLD, and to assess whether perceived LLD resolved with time in most patients.
Methods and Materials
This study retrospectively reviewed radiographs of 140 consecutive patients undergoing primary THA by a single surgeon via a direct anterior approach, calculating postoperative change in limb length (ΔL). Patient perceptions of LLD were recorded at standard postoperative visit intervals. A p-value of 0.05 was used to determine statistical significance.
Results
Of 130 patients (mean ΔL = +7.9 mm), 22 patients endorsed perceived postoperative LLD and the remainder were asymptomatic (mean ΔL +11.1 mm vs +7.3 mm, p=0.03). 17 reported mild symptoms and 5 reported severe (mean ΔL +10.2 mm vs +13.8 mm, p=0.4). After 1 year, 45% (10) patients reported complete resolution of perceived LLD (mean follow-up 364 days), 18% (4) reported notable improvement, and 36% (8) reported no improvement. Four excluded patients endorsed perceived LLD (2 mild, 2 severe), which resolved after contralateral THA.
Discussion and Conclusion
This study noted a correlation between increasing postoperative ΔL and perceived LLD. A majority of patients (63%) experienced either improvement or full resolution of symptoms during the follow-up period. This data may have a role in reassuring the orthopaedic surgeon and the patient regarding the natural course of postoperative LLD. Further investigation is needed to help identify risk factors for persistent LLD.
Level of Evidence
Level III (Prognostic)
... Furthermore, it is associated with increased patient dissatisfaction and remains a leading cause of litigation against orthopedic surgeons in the United States [1,7,8]. Though most patients with a perceived LLD postoperatively improve with nonoperative modalities of treatment, a minority may experience a significant degree of disability, usually pertaining to persistent pain or mechanical symptoms such as a limp or gait abnormality [9][10][11][12]. ...
... The patient should be aware of a high incidence of perceived LLD postoperatively, which resolves with time or nonoperative modalities of treatment in the vast majority of cases [3,5,12,17]. Those with end-stage osteoarthritis and preoperatively shortened extremities will commonly have soft tissue contractures causing LLD, which typically equalize upon participation in rehabilitation and with the passage of time [2,9,16]. ...
... In addition to clinical measurements, a thorough comparison of preoperative versus postoperative leg lengths must be radiographically measured and documented. There have been reports of patients with perceived LLDs postoperatively, the vast majority of whom had resolved symptoms by 6 months postoperatively [2,5,9,16]. Those with persistent symptoms may be trialed with a shoe lift used on the leg perceived to be shorter, though such lifts must be used with caution as they can preclude the release of contracted soft tissues, potentially perpetuating the problem [5]. ...
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.
... A perceived LLD may refer to anatomical or functional differences secondary to changes in biomechanical forces and the relationship between the pelvis and lumbar spine [3e6]. Preoperative LLD has also been associated with postoperative patient-perceived LLD and poor functional outcomes [3,7]. ...
... However, single AP plane pelvic radiograph is the common method in the clinic to assess leg lengths. Multiple studies have used single AP plane radiographic images to assess how preoperative LLD may impact patient perceived-LLD, functional outcomes, and patient satisfaction postoperatively [3,34]. Additionally, clinical outcome measures were not available, thus prohibiting comparisons between those with and without LLD and subsequent analysis of clinical outcomes. ...
Background:
Leg length and hip offset are important principles in total hip arthroplasty (THA). Patients may endorse leg length differences (LLD) postoperatively that may be anatomical or functional. The objective of this study was to determine the normal radiographic variation in leg length and hip offset in a preosteoarthritic population without a THA.
Methods:
A retrospective study was completed using data from the Osteoarthritis Initiative, a prospective longitudinal study. Patients at risk of developing or with early osteoarthritis without inflammatory arthritis or prior THA were included. Measurements were made from full limb length anterior-posterior (AP) radiographs. Multiple linear regression models were employed to predict side-to-side differences in LLD, Δ femoral offset (FO), Δ abductor muscle length (AML), Δ abductor lever arm, and Δ AP pelvic offset.
Results:
The mean radiographic LLD was 4.6 mm, with 12 mm within 1 standard deviation. No significant differences were detected between LLD and sex, age, body mass index, or height. The median radiographic differences in FO, AML, abductor lever arm, and AP pelvic offset were 3.2 mm, 4.8 mm, 3.6 mm, and 3.3 mm, respectively. Height was predictive of Δ FO, while both height and age were predictive of Δ AML.
Conclusions:
Radiographic leg length variations in a population without symptomatic or radiographic osteoarthritis exist. FO and AML are dependent on patient characteristics. Preoperative radiographic LLD is not predicted by age, gender, body mass index, or height. It should be stressed that anatomic reconstruction is one of the many goals of arthroplasty and can stand in conflict with the priority and primary goals of stability and fixation, which should be prioritized.
... The tolerance for LLD following THA remains unclear [24,25], but shorter LLD has been linked to higher patient satisfaction [26]. While Kim et al. highlighted the benefits of simBTHA in minimizing postoperative LLD [27], this study found no significant differences in LLD between the two groups. ...
Background
To date, no study has compared simultaneous bilateral total hip arthroplasty (simBTHA) with staged BTHA (stgBTHA) using the anterolateral-supine approach (ALSA). This study compared the outcomes and cost-effectiveness of simBTHA and stgBTHA using ALSA.
Methods
This retrospective cohort study was conducted on patients who required bilateral ALSA THA at the time of their initial medical evaluation between August 2015 and January 2023. Patients were divided into two groups: simBTHA and stgBTHA. Demographic data, including age, sex, body mass index (BMI), and American Society of Anesthesiologists Physical Status (ASA-PS) scores, were collected. Operative outcomes such as surgical time, blood loss, autologous and allogeneic blood transfusions, and time to ambulation were compared. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) hip score, Japanese Orthopaedic Association Hip-disease Evaluation Questionnaire (JHEQ), and Forgotten Joint score-12 (FJS-12). Postoperative complications, revisions, readmissions, and mortality within 90 days were also recorded. The total cost, length of stay (LOS), and time interval between surgeries in the stgBTHA group were analyzed.
Results
A total of 129 patients were included: 104 in the simBTHA group and 25 in the stgBTHA group. The preoperative ASA-PS significantly differed between the two groups (P < 0.01), but other demographic data were not significantly different. The simBTHA group had significantly shorter surgical times (156 min) compared to the stgBTHA group (175 min) (p = 0.02). Blood loss was similar between the two groups (670 mL for simBTHA and 629 mL for stgBTHA). There were no significant differences in the time to ambulation, postoperative complications, or clinical outcomes between the two groups. However, the simBTHA group had a significantly lower total cost (83.2%, p < 0.01) and shorter LOS (20.5 days) compared to the stgBTHA group (30 days) (p < 0.01). No significant differences in complication rates, revisions, or readmissions were observed between the groups.
Conclusions
SimBTHA with ALSA provides comparable clinical outcomes to stgBTHA while offering significant advantages in terms of reduced costs and shorter hospital stays. For patients with suitable health conditions, simBTHA is a preferable choice due to its faster recovery and greater cost-effectiveness.
... Revision arthroplasty due to LLI represents 0.5% of all revision surgeries and has traditionally been considered a last resort for persistent discomfort or significant instability after conservative treatment [9]. Most patients see their symptoms improve within the first postoperative year, with time and physical therapy [5,10,11]. Moreover, revision arthroplasty is technically demanding and carries risks like bone defects and dislocation due to removing wellintegrated stems and detensioning soft tissues [5]. ...
Background
Limb length inequality (LLI) is a leading cause of patient dissatisfaction and litigation after total hip arthroplasty (THA). However, the surgical treatment of this complication remains controversial. In this retrospective and observational study, we evaluated the results obtained from 31 patients who underwent revision surgery for symptomatic LLI after conservative treatment had failed. Our primary endpoint was the radiographic correction of LLI. Secondary endpoints included assessing the improvement in quality of life (QoL) after surgical treatment [using the Harris Hip Score (HHS) and the 12-item Short Form Survey (SF-12)] and tracking possible complications (e.g., dislocation, residual instability).
Materials and methods
Type of surgery, implanted materials, preoperative sciatic nerve deficit, and the development of postoperative complications were recorded. Radiographic assessment was performed by measuring LLI, Femoral Offset (FO), Acetabular Offset (AO), Global Offset (GO), and height of the Center of Rotation (CORL), and calculating the difference with the contralateral side and postoperative measurements. Clinical assessment was performed by having patients answer to the HHS and the SF-12, which comprises a Physical Component Summary (PCS-12) and a Mental Component Summary (MCS-12).
Results
LLI, GO, and CORL showed a statistically significant variation between preoperatory and postoperatory radiographs. The same was found to apply also to clinical results, the HHS, and the SF-12. Linear regression analysis showed a single association between sex and postoperative HHS. No other association was found to be statistically significant.
Conclusions
In selected patients who have symptomatic structural LLI after primary THA, revision surgery can be a valid approach to restore the proper limb length and to improve the clinical outcomes with an acceptable risk of complications and instability.
... In our study, half of the patients who perceived LLD at 6 weeks remitted at 1-year follow-up. This is consistent with findings of Adams et al. [16] our study had a larger cohort and a longer follow-up time of at least five years. Between 1 year and 5 years patients' perception of pLLD remained almost unchanged but the subjective negative effect of pLLD reduced persistently. ...
Background
Leg length discrepancy (LLD) after total hip arthroplasty (THA) is a clinical entity that deteriorates clinical outcomes and patients’ satisfaction. Few articles have compared LLD after THA by different surgical approaches.
Methods
A total of 358 consecutive patients who underwent primary THA between January 2016 and November 2018 were retrospectively reviewed. All 4 surgeons performed THA through both direct anterior approach (DAA) and posterior lateral approach (PLA). The primary outcome measurement was LLD. LLD was measured on post-operative anteroposterior bilateral hip radiograph. The secondary outcomes were acetabular abduction, acetabular anteversion, perceived LLD (pLLD) and HHS at 6 weeks, 1 year and 5 years. Intergroup analyses were performed using the Chi-square test for enumeration data and the independent sample t-test for quantitative data.
Results
There was no inter-group difference in terms of patients’ demographics. The DAA group had decreased LLD compared to the PLA group (3.0 ± 5.9mm vs. 4.2 ± 4.5mm, p = 0.027). Meanwhile, the DAA group had a smaller acetabular anteversion than the PLA group (12.9 ± 2.9 vs. 18.4 ± 2.9, p < 0.01). At 6-week follow-up, the DAA group had higher HHS (82.2 + 6.2 vs. 80.5 + 6.6, p = 0.015) and less pLLD (P = 0.001) compared to the PLA group.
Conclusions
DAA results in more accurate leg length equalization, reduced pLLD, and improved short-term outcomes compared with PLA.
... Femoral side complications caused by inaccurate stem positioning were main causes of early revision and patients' dissatisfaction [4], mainly consisting of subsidence [5], leg length discrepancy (LLD) [6,7], periprosthetic fracture [8], periprosthetic infection or even loosening [5,9]. The occurrence of femoral side complications seriously affected patients' life quality and added additional financial burden to patients [10]. ...
Postoperative complications due to inaccurate prosthesis positioning are the main causes of early revision. The aim of this study was to (1) determine whether novel designed whole-process robotic assisted hip system allowed better radiographic outcomes and lower complications risk on the femoral side particularly stem subsidence compared to conventional THA, and to (2) identify the comparison of early clinical outcomes. 72 patients were initially enrolled and randomly divided into 2 groups. Finally, only 65 patients (31 RA-THAs, 34 C-THAs) were analyzed who had full 18-month follow-up data. Radiographic follow-up was performed at immediate and 6-month postoperatively, while clinical follow-up at 18-month postoperatively. Stem-related radiographic outcomes, femoral side complications and clinical scores were compared. The robotic arm allowed better radiographic outcomes of the femoral side, including a higher canal fill ratio (CFR) at B1 (P = 0.040), more neutral stem alignment (P = 0.029), lower subsidence (P = 0.023) and lower leg length discrepancy (LLD) (P = 0.010). In addition, low CFR at B1 (P = 0.001) was found the risk factor for subsidence. However, early clinical outcomes were consistent between both groups. The novel designed whole-process robotic assisted hip system covers both femoral and acetabular side operations. It allows accurate and safe manipulation of femoral side, including better stem-related radiographic outcomes and lower risk of subsidence and LLD. However, no advantage of robotic system in early clinical score was identified. Clinical trial registration number: ChiCTR2100044124.
... It is usually referred as in plus or in minus depending on its relationship with the contralateral, healthy limb. Although the incidence of LLD is reported up to 27% after THR surgery [5], only one third of patients with LLD greater than 1 cm are symptomatic [6]. When symptomatic, LLD can be associated with patient dissatisfaction, the need to wear a permanent shoe lift and, if not compensated by the patient, the need for revision surgery. ...
... Another risk factor for inconsistent LLD is a long R-LLD. Adams et al. reported that patients who experienced a P-LLD after surgery had a significantly longer R-LLD initially than those who did not [19]; a long R-LLD is common in patients with DHOs. It may be corrected by pelvic tilt and tension of the soft tissue around the hip joint, resulting in inconsistency with the P-LLD. ...
Background
We aimed to examine the inconsistency between radiographic leg length discrepancy (R-LLD) and perceived LLD (P-LLD) in patients with dysplastic hip osteoarthritis and to evaluate the factors that can cause such inconsistency.
Methods
We conducted a retrospective study on 120 patients. An inconsistent LLD was defined as a condition in which the P-LLD was shorter than the R-LLD by > 5 mm. We compared relevant data on the general characteristics of the patients and the radiological findings between consistent (group E, 92 cases [76.7%]) and inconsistent LLDs (group S, 28 cases [23.3%]).
Results
The number of patients with a history of hip surgery on the affected side and the Japanese Orthopedic Association classification pain scores were significantly higher in group S than in group E (32.1% vs. 10.8%, respectively; P = 0.015, and 21.7 ± 7.0 vs. 17.5 ± 8.2, respectively; P = 0.036). The pelvic oblique angle and length of the R-LLD were significantly higher in group S than in group E (2.9 ± 2.5° vs. 0.3 ± 2.3°, respectively; P < 0.01, and 17.2 ± 8.9 mm vs. 6.3 ± 8.4 mm, respectively; P < 0.01). Multivariate logistic analysis revealed that the pelvic oblique angle (odds ratio [OR]: 1.80, 95% confidence interval [CI]: 1.28–2.52; P < 0.01) and length of the R-LLD (OR: 2.75, 95% CI: 1.24–6.12; P = 0.013) were independent risk factors of inconsistent LLD.
Conclusion
The pelvic oblique angle and a long R-LLD were independent risk factors of inconsistent LLD in patients with dysplastic hip osteoarthritis. Therefore, hip surgeons should consider P-LLD rather than R-LLD to understand the need for conservative intervention.
Leg length discrepancy (LLD) is a common and often distressing complication following total hip arthroplasty (THA), impacting both functional outcomes and patient satisfaction. This chapter explores the causes, implications, and management strategies for LLD, focusing on revision THA for LLD. LLD can be categorized into anatomic LLD (ALLD) and functional LLD (FLLD), each requiring tailored approaches for optimal management. ALLD typically arises from surgical factors such as implant selection or surgical technique, while FLLD is attributed to non-hip factors like muscle imbalance or pelvic tilt. Management strategies encompass preoperative templating, intraoperative measurements, and postoperative rehabilitation. Surgical interventions are considered for cases of severe or symptomatic LLD, including femoral head shortening or revision surgery. By addressing LLD comprehensively and individualizing interventions, surgeons can enhance postoperative function and patient satisfaction in THA.
Background:
The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA).
Methods:
Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."
Results:
Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics.
Conclusions:
The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.
Background
Leg length discrepancy (LLD) is a common complication of total hip arthroplasty (THA). However, the relationship between femoral prosthesis filling, proximal femoral morphology, and acetabular prosthesis positioning with postoperative LLD and clinical outcomes is unclear. The aims of this study were to investigate the influence of canal flare index (CFI), canal fill ratio (CFR), center of rotation (COR), and femoral offset (FO) on (1) postoperative LLD; and (2) clinical outcomes in the two stem designs with different coating distribution.
Methods
The study cohort included 161 patients who underwent primary cementless THA between January 2021 and March 2022 with either proximal coating or full coating stems. Multivariate logistic regression was used to assess the effect of CFI, CFR, COR, and FO on postoperative LLD, and linear regression to assess their effect on clinical outcomes.
Results
No statistical difference was found in clinical outcomes or postoperative LLD between the two groups. High CFI (p = 0.014), low ΔVCOR (p = 0.012), and Gender (p = 0.028) were found independent risk factors for LLD one day postoperative. High CFI was also an independent risk factor for postoperative subjectively perceived LLD (p = 0.013). CFR at the level of 2 cm below the LT (p = 0.017) was an independent risk factor for Harris Hip Score.
Conclusions
Proximal femoral morphology and acetabular prosthesis positioning but not femoral prosthesis filling affected the LLD. High CFI was an independent risk factor for postoperative LLD and subjectively perceived LLD, and low ΔVCOR was also an independent risk factor for postoperative LLD. Women were susceptible to postoperative LLD.
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.
Patient and methods:
Patients who had baseline antero-posterior pelvis radiographs from the Osteoarthritis Initiative were included. A DL algorithm was created to identify LLD-relevant landmarks (i.e., teardrop, 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. Inter-class 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 teardrop and lesser trochanter landmarks as the standard LLD method, only measuring LLD using the teardrop 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.
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.
Reduced limb length discrepancy and more accurate cup positioning are purported benefits of using fluoroscopy for total hip arthroplasty (THA). The authors compared limb length discrepancy and cup position in 200 patients (group I, posterior approach without fluoroscopy; group II, anterior supine approach with fluoroscopy) who underwent primary THA. Mean limb length discrepancy was 2.7 mm (SD, 5.2 mm; range, −9.8 to 20.9 mm) and 0.7 mm (SD, 3.7 mm; range, −11.8 to 10.5 mm) for groups I and II, respectively (P=.002). In group I, 7% of hips had limb length discrepancy greater than 1 cm compared with 3% in group II. Mean cup inclination measured 40.8° (SD, 5.0°; range, 26.1°–53.7°) in group I and 43.4° (SD, 5.6°; range, 31.3°–55.9°) in group II (P=.008). In group I, 96% of cups had inclination within 10° of the mean compared with 92% in group II (P=.24). Mean anteversion measured 35.3° (SD, 7.1°; range, 17.8°–60.7°) in group I and 25.9° (SD, 8.2°; range, 1.5°–44.8°) in group II (P=.0001). In group I, 87% of hips exhibited anteversion within 10° of the mean compared with 76% in group II (P=.045). Although the anterior approach with intraoperative fluoroscopy reduced mean limb length discrepancy, the clinical significance of this reduction is unclear. Fluoroscopy reduced the incidence of limb length discrepancy greater than 1 cm. However, the use of fluoroscopy did not help to improve the precision of cup positioning. [Orthopedics. 2015; 38(5):e380–e386.]
Discrepancy of leg length is often considered to be a problem after total hip replacement and can adversely affect an otherwise excellent outcome. Furthermore, it has been associated with patient dissatisfaction and remains one of the most common reasons for litigation against the orthopedic community. As a consequence of the need to equalize leg length, several authors have sought to validate methods of minimizing limb length discrepancy based on preoperative planning with preoperative radiological templates or intraoperative methods of measurement. In this article, we present a review of the limb length discrepancy in total hip arthroplasty, its implications and several techniques to avoid it. We recommend that a combination of the above mentioned methods will give the best chance for the surgeon to minimise the risk of leg length discrepancy following total hip replacement.
The effect of leg length differences on early clinical outcome after total hip arthroplasty remains uncertain.
We performed a prospective study on 94 patients who were evaluated preoperatively and one year after surgery for clinical leg length differences, which were then compared with radiological measurements. The effect of leg length differences on walking ability, limp, pain and patient satisfaction was studied.
The mean clinical leg length difference after operation was 0.05 cm (–1.5 to 1.5, SD 0.5). Clinical and radiological measurements correlated poorly (ω=0.36 pre- and ω=0.186 postoperatively). Patients with a shorter operated leg on clinical assessment were more prone to limping (p<0.05), and patients with a longer leg had more pain compared to patients with equal leg lengths (p<0.05). Walking ability, Harris Hip Score and patient satisfaction were only marginally affected by leg length differences.
Virtually equal leg length was achieved for most patients but small differences had a negative influence in relation to limping and pain. Patients should be counselled pre-operatively about possible leg length differences and associated symptoms.
Discrepancy in leg length after total hip replacement has been associated with patient dissatisfaction. We prospectively studied 200 consecutive patients undergoing unilateral Charnley hip replacements to identify whether there is a demonstrable association between such disparity and postoperative function. Radiological measurements between defined points on the pelvis and femur of the operated hip were compared with the same points on the contralateral joint. A lengthening index was derived and statistical analysis used to compare this with validated functional outcome scores (Harris hip score and the SF36 Health Survey) and patient satisfaction. Our results showed no statistical association between leg-length discrepancy after hip arthroplasty and functional outcome or patient satisfaction.
A survey of the American Association of Hip and Knee Surgeons was performed to investigate the perceptions and experiences of medical malpractice litigation and related concerns among its active members. Responses showed that 78% of responding surgeons had been named as a defendant in at least 1 lawsuit alleging medical malpractice. Sixty-nine percent of lawsuits in the survey had been dismissed or settled out of court, and median settlement amounts were in the range of 99,000. Nerve injury was the most commonly cited source of litigation, followed by limb length discrepancy, infection, vascular injury, hip dislocation, compartment syndrome, deep vein thrombosis, chronic pain, and periprosthetic fracture. Survey data suggest that there are targets for surgeon education and awareness that could improve the quality of patient communication and the informed consent process.
The aim of this postal survey was to determine the prevalence and impact of patient-perceived leg length discrepancy (LLD) at 5-8 years after primary total hip replacement (THR). A postal audit survey was undertaken of all consecutive patients who had a primary unilateral THR at one elective orthopaedic centre between April 1993 and April 1996. The questionnaire included the Oxford hip score (OHS) and questions about LLD. Questionnaires were received from 1,114 patients. In total, 329 THR patients (30%) reported an LLD, although radiographic analysis revealed that only 36% of these patients had anatomical LLD. Patients with a perceived LLD had a significantly poorer OHS (p < 0.001) and reported more limping than those patients without a perceived LLD. This study found that a third of patients perceived an LLD after THR and that perceived LLD was associated with a significantly poorer midterm functional outcome.
Preoperative templating provides several benefits to the patient, surgeon, and hospital. Appropriate implant selection and sizing optimizes surgical workflow and leads to efficient care-delivery systems. Accurate templating establishes intraoperative targets for component position and reduces complications such as leg length inequality, impingement, wear, dislocation, and fracture, all of which lead to decreased patient satisfaction. Recent technological advances in preoperative imaging include a better understanding of patient-specific pelvic motion allowing the surgeon to preoperatively address the risk of lumbar pathology with adjustments in component placement and bearing choice. The introduction of two-dimensional to three-dimensional (3D) radiographs, biplanar low-dose radiographs, and computed tomography scans with 3D reconstructions have all allowed for a more comprehensive preoperative planning in 3D. This article will review the fundamentals of templating before total hip arthroplasty with an emphasis on how to incorporate and implement patient-specific pelvic motion and 3D templating into practice.
Background:
Leg length discrepancy (LLD) occurs in about 25% of cases after total hip arthroplasty (THA) and adversely affects function if greater than 10mm. When using the direct anterior approach (DAA), limb length control is considered easier with a standard operating table than with a traction table. However, this assumption has not been confirmed. More specifically, no studies have used EOS imaging, which is currently the reference for assessing limb length. The objectives of this retrospective study were: (1) to use EOS imaging to determine whether THA via the DAA on a standard table allowed satisfactory limb length control; (2) whether LLD was associated with other parameters such as age, gender, body mass index (BMI), or side; and (3) to compare clinical score values between patients with and without LLD.
Hypothesis:
The DAA without a traction table allows satisfactory limb length control as assessed using 3D EOS imaging.
Material and methods:
This retrospective descriptive study included 56 patients who underwent primary THA via the DAA between March 2013 and June 2014. LLD was measured on pre- and post-operative EOS images, using sterEOS™ 3D software. Age, gender, BMI, and side of THA were collected. The 12-item Short Form score, Harris Hip Score, and Postel-Merle d'Aubigné score were determined to look for radio-clinical correlations.
Results:
Of the 56 patients, 15 (26.8%) had an LLD >10mm before THA and 12 (21.4%) after THA. Limb length equality was restored in 7 patients with 1 with a shorter and 1 with a longer limb before THA. In 5 patients with equal limb length before THA, the operated limb was lengthened after THA, by a mean of 8.92mm (range, 5.8-10.8mm). Thus, in all, 5/56 (8.9%) patients experienced a detrimental change in limb length due to the surgery. No statistically significant differences were found between patients with and without LLD regarding age, gender, BMI, side, or clinical scores.
Discussion:
Although the frequency of LLD after THA in our study was consistent with earlier reports, our results show that good limb length control can be obtained via the DAA with a standard operating table. Thus, 7 of the 11 patients with a shorter limb and 1 of 4 with a longer limb before THA had equal limb lengths after THA, and only 8.9% of patients experienced a detrimental increase in limb length after THA. The DAA without a traction table allows satisfactory intra-operative limb length control based on visualisation of anatomical landmarks (antero-superior iliac spines and medial malleoli). This technique is therefore valuable for limiting the risk of LLD. When combined with 3D EOS planning, it may increase the accuracy of limb length adjustment.
Level of evidence:
IV, retrospective study with no control group.
We hypothesised that a femoral array placed into bone or an external (pinless) reference marker made no difference to leg length discrepancy in patients undergoing navigated total hip arthroplasty. Consecutive patients undergoing navigated total hip arthroplasty. 162 patients. No statistical difference between preoperative leg length discrepancy (p = 0.524). Mean intraoperative change was 3.7 mm and 4.6 mm (p = 0.262). The mean change in leg length measure post operatively was 4.2 mm and 4.1 mm (p = 0.656). No significant difference in leg length discrepancy between a pinless reference markers and a femoral array placed into the bone.
Discrepancy in leg length after total hip replacement has been associated with patient dissatisfaction. We prospectively studied 200 consecutive patients undergoing unilateral Charnley hip replacements to identify whether there is a demonstrable association between such disparity and postoperative function. Radiological measurements between defined points on the pelvis and femur of the operated hip were compared with the same points on the contralateral joint. A lengthening index was derived and statistical analysis used to compare this with validated functional outcome scores (Harris hip score and the SF36 Health Survey) and patient satisfaction.
Our results showed no statistical association between leg-length discrepancy after hip arthroplasty and functional outcome or patient satisfaction.
Background:
Greater than 75% of arthroplasty surgeons report having been the subject of a malpractice lawsuit. Despite this, few studies have analyzed the causes of litigation following total joint arthroplasty in the United States.
Methods:
This study is a retrospective analysis of malpractice lawsuits following total hip and knee arthroplasty using VerdictSearch, a database encompassing legal cases compiled from February 1988 to May 2015. Complications leading to litigation were categorized and assessed for patient, surgeon, and lawsuit factors. All monetary awards were reflected for inflation.
Results:
A total of 213 lawsuits were analyzed (119 total hip and 94 total knee arthroplasty cases). Overall, 15.0% of cases ended in settlement and 29.6% ended in a verdict in favor of the plaintiff (physician loss). The average payment for cases lost in court (3,679,572) was significantly larger than cases that ended in settlement (822,098) (P = .006). The most common complication following hip arthroplasty was "nerve injury" (29 cases, settlement rate: 10.3%, physician loss rate: 53.9%, and average payment: 451,867). Technical complications were the most likely complications to result in a physician loss (P = .019).
Conclusion:
While complications like "pain and weakness" are less likely to result in favorable litigation for patients, the presence of an objective technical complication or nerve injury was associated with an increased risk of a physician loss and a higher payment.
Background:
Patients with advanced hip arthritis can present with multifactorial limb length discrepancies (LLDs) owing to bony shortening from growth arrest, proximal hip migration, soft-tissue contractures, and pelvic obliquity. The patient perceives an LLD that is a combination of true LLD and apparent LLD.
Methods:
We retrospectively reviewed 7 cases with multifactorial mean perceived LLD of 7.7 cm (range, 3.6-11 cm) that underwent primary total hip arthroplasty and auxiliary soft-tissue procedures. Perceived LLD, true LLD, and apparent LLD were defined and were compared before and after surgery in this cohort of patients with a mean follow-up of 57.4 months.
Results:
The mean perceived LLD at final follow-up was 1.0 ± 0.9 cm compared with that of 7.7 ± 2.6 cm preoperatively (P < .05). Postoperative true LLD was 0.7 ± 0.8 cm compared with that of 3.2 ± 0.8 cm preoperatively (P < .05). At final follow-up, all 7 patients were ambulating without any assistive devices and were satisfied with their surgical outcome.
Conclusion:
With careful preoperative clinical and radiographic assessments as well as planning for multifactorial perceived LLD, this can be adequately corrected with primary total hip arthroplasty and auxiliary soft-tissue procedures resulting in good radiologic and functional outcomes.
Restoration of normal hip biomechanics is a key goal of total hip arthroplasty (THA) and favorably affects functional recovery. Furthermore, a major concern for both the surgeon and the patient is preservation or restoration of limb length equality, which must be achieved without compromising the stability of the prosthesis. Here, definitions are given for anatomic and functional limb length discrepancies and for femoral and hip offset, determined taking anteversion into account. Data on the influence of operated-limb length and offset on patient satisfaction, hip function, and prosthesis survival after THA are reviewed. Errors may adversely impact function, quality of life, and prosthetic survival and may also generate conflicts between the surgeon and patient. Surgeons rely on two- or three-dimensional preoperative templating and on intraoperative landmarks to manage offset and length. Accuracy can be improved by using computer-assisted planning or surgery and the more recently introduced EOS imaging system. The prosthetic's armamentarium now includes varus-aligned and lateralized implants, as well as implants with modular or custom-made necks, which allow restoration of the normal hip geometry, most notably in patients with coxa vara or coxa valga. Femoral anteversion must also receive careful attention. The most common errors are limb lengthening and a decrease in hip offset. When symptoms are caused by an error in length and/or offset, revision arthroplasty may deserve consideration.
In a single-surgeon series of 119 patients with unilateral primary uncemented total hip arthroplasty, four leg-length discrepancy measurement methods (absolute, relative, trochanteric, standardized-trochanteric) were analyzed for their impact on WOMAC score, Oxford Hip Score and self-perceived leg-length discrepancy. After adjustment for age, gender and BMI, postoperative WOMAC scores correlated only with clinical absolute measurements of leg elongation (P=0.05). Self-perceived leg-length discrepancy corresponded best to the clinically measured relative leg-length discrepancy (11 mm perceived vs. 7 mm unperceived; P=0.04) while there was no significant correspondence with radiographic measurements or leg elongation magnitudes. Within the <10 mm range of mean postoperative leg length discrepancy in the studied series, its impact on the overall clinical satisfaction was detectable but not considerable.
Limb lengthening is not uncommon after total hip replacement and may cause subjective problems for patients. We have studied 150 total hip replacements to investigate the operative change in limb length. A radiologic evaluation is used and is shown to be accurate. One hundred forty-four limbs were lengthened an average of 15.9 mm. Slightly less lengthening was observed if the greater trochanter was removed as part of the operative procedure. For subjective complaints 40 (27%) patients required heel lifts on the unoperated side to gain a satisfactory gait pattern. Partial sciatic nerve palsies also occurred in this series (3.3%) subsequent to total hip replacements. These palsies did not correlate with sex, lengthening of the extremity, or operative procedure, but did correlate with repeat surgeries and in all instances the condition resolved or improved.
Leg length inequality (LLI) in 55 patients with cemented total hip arthroplasty (THA) was measured from weight-bearing anteroposterior (AP) hip radiographs. The mean radiologic LLI was 8.7 mm in unilateral and 11.6 mm in bilateral THA, differing significantly from the clinically measured values (2.8 mm and 4.2 mm, respectively). LLI as a cause of aseptic loosening and unexplained pain warrants investigation in THA patients.
The radiographs and prospective records of 1284 (1152 primary and 135 revisions) Charnley low friction arthroplasties performed by one surgeon were studied in reference to postoperative elongation of the limb and lateralization or medialization of the center of rotation of the hip joint and their effect on postoperative nerve palsy. Displacement of the center of the hip joint in relation to fixed points on the pelvis was measured. In primary low friction arthroplasties, leg lengthening ranged from 0.4 to 4 cm; in the revision group, they ranged from 0.04 to 5.8 cm. Sixty-six hips were lengthened more than 2 cm. The center of rotation of the hip was lateralized in 18.1% of cases and medialized in 61.9%. A single case of postoperative sciatic nerve palsy (the result of laceration of the sciatic nerve at surgery) was identified. These study results indicate that nerve injuries after total hip arthroplasty may be caused by local insult, and may not be related to elongation of the limb or postoperative alteration of the center of rotation of the hip.
The authors questioned whether leg length discrepancies of the magnitude ordinarily seen after total hip reconstruction (<2 cm) would substantially alter hip joint forces. Using conventional gait analysis techniques to ascertain intersegmental resultant hip forces and moments, the authors used lifts to simulate leg length discrepancies of 2.3, 3.5, and 6.5 cm in 7 normal subjects. The 2.3-cm lift produced no changes. On the side of the lift (long limb), the 3.5- and 6.5-cm lifts modestly decreased mean peak intersegmental resultant hip forces by 6% and 12%, respectively, but not moments. The changes were, however, variable, with a few subjects showing increases and the rest showing decreases in selected forces or moments. On the side opposite to the lift (short limb), the 3.5- and 6.5-cm lifts increased mean peak intersegmental resultant hip forces by 2% to 12%, but not moments except in 1 case (8%). It is concluded that leg length discrepancies of the sort commonly seen after total hip reconstruction would likely cause no substantial changes in hip forces.
A consecutive series of 100 patients undergoing primary total hip arthroplasty were assessed for functional leg-length inequality (FLLI). In addition, the medical records of all patients treated for FLLI by the senior author (C.S.R.) in the past 15 years was reviewed. A questionnaire was distributed to the members of the Hip Society specifically to query the prevalence, etiology, and management of FLLI. Fourteen percent of patients were noted to have pelvic obliquity and FLLI.1 month after surgery. All had resolution of the symptoms by 6 months after surgery. Nine patients have been identified over the past 15 years with persistent FLLI. Among the causes suggested by respondents to the questionnaire are tightness of periarticular soft tissues with resultant pelvic obliquity and degenerative conditions of the spine with contracture. Methods of treatment and prevention are discussed.
The postoperative leg-length discrepancy was determined radiographically for a consecutive series of 351 patients (408 hips) who underwent bilateral or unilateral primary total hip replacement using a single method of leg-length equalization by preoperative planning with overlay templates. The method of equalization was performed by a measurement of the femoral head and neck segment to be resected from a reference point at the superior aspect of the dislocated femoral head. The amount of femoral bone resected was determined preoperatively by determining the dimensions of the acetabular component thickness and the femoral component head and neck height that would be replacing this resected bone and adjusting this distance for any preexisting leg-length discrepancy. Using this leg-length equalization method, the length of the modular femoral head neck was chosen preoperatively, rather than using soft tissue tension across the prosthetic hip joint to determine whether the leg lengths were equal. Postoperative leg lengths were determined radiologically from a measurement from the acetabular teardrop to the lesser trochanter. Ninety-seven percent of the patients had a postoperative leg-length discrepancy that was less than 1 cm, and 86% had a leg-length difference that was 6 mm (1/4 inch) or less. The average postoperative discrepancy for these 351 patients was 1 mm.
Meralgia paresthetica consists of pain and dysthesia in the lateral thigh caused by entrapment of the lateral femoral cutaneous nerve (L2-L3) underneath the inguinal ligament. Abdominal distension, tight clothing, and hip hyperextension are all described causes of this condition. To our knowledge this has never been attributed to a limb length discrepancy. We present a 51-year-old man with a long-standing history of right sided meralgia paresthetica. History and physical and radiological examination were unrewarding except that his left leg was shorter than the right by 2 cm. Nerve conduction studies of the lateral femoral cutaneous nerve on the left had a normal latency and amplitude but were absent on the right. To prove the hpothesis that the limb length discrepancy was responsible for the condition, a single subject study was performed. The presence or absence of pain and dysesthesia in the right thigh was the observed behavior. Intervention consisted of wearing a 1.5-cm lift in the left or right shoe for 2 weeks each with an intervening 2-week lift-free period. Pain was recorded on a numeric scale and numbness as being present or absent. There was continuing pain without and with the lift in the right shoe but no pain or numbness with the lift in left shoe. It was concluded that the limb length discrepancy was responsible for the meralgia paresthetica. Pertinent literature and possible pathomechanics are discussed.
Limp is one of the most frustrating persistent symptoms after hip arthroplasty for both the patient and surgeon. There are a multitude of causes of limp; however, leg-length inequality is the leading culprit. Leg-length inequality can lead to anger, litigation, morbidity, and ultimately revision surgery. However, geometrically equal leg lengths may not be an attainable goal in all patients. The stability of the total hip arthroplasty is intimately related to leg length, and equality may need to be sacrificed for stability. Therefore, both the patient and the surgeon should have realistic expectations and an awareness of this problem.
Although most patients with limb-length discrepancy following total hip arthroplasty have manageable symptoms, others may be disabled as a result of pain or functional impairment. In these patients, reoperation may be indicated to equalize the limb lengths. There is a paucity of published data regarding the outcome of surgical intervention to treat this problem. The purpose of the present study was to evaluate the results of revision hip surgery for the treatment of symptomatic limb-length discrepancy.
We retrospectively reviewed the clinical and radiographic records of patients who had undergone revision hip surgery at our institution for the treatment of a symptomatic limb-length discrepancy following a previous total hip arthroplasty. We identified twenty-one patients (twenty-one hips) who had an average age of sixty-six years at the time of revision hip arthroplasty. The average duration of follow-up was 2.8 years, and no patient was lost to follow-up. The indications for revision hip arthroplasty were severe hip and/or back pain for eleven patients, instability of the hip for eight, hip pain and ipsilateral limb paresthesia for one, and hip pain and ipsilateral foot drop for one.
Revision arthroplasty was performed at a mean of eight months (range, six days to six years) after primary total hip replacement. The mean limb-length discrepancy at the time of the revision was 4 cm (range, 2 to 7 cm). Following revision arthroplasty, which involved revision of a malpositioned acetabular and/or femoral component, equalization of the limb lengths was achieved in fifteen patients. In the remaining six patients, the mean discrepancy had decreased to 1 cm. The mean Harris hip score improved significantly, from 56.5 points before the revision to 83.2 points at the time of the latest follow-up (p < 0.005). All but two patients were satisfied with the outcome of the revision surgery.
Limb-length discrepancy following hip arthroplasty can be associated with pain, paresthesia, and hip instability. In these patients, careful evaluation of the position and orientation of the components may reveal the cause of the discrepancy. Revision arthroplasty may be indicated when a surgically correctable cause of limb-length discrepancy can be identified.
We assessed leg length discrepancy and hip function in 90 patients undergoing primary total hip arthroplasty before surgery and at three and 12 months after. Function was measured using the Oxford hip score (OHS). After surgery the mean OHS improved by 26 points after three months and by 30 points after 12.
After operation 56 (62%) limbs were long by a mean of 9 mm and this was perceived by 24 (43%) patients after three months and by 18 (33%) after 12. The mean OHS in patients who perceived true lengthening was 27% worse than the rest of the population after three months and 18% worse after 12. In 55 (98%) patients, lengthening occurred in the femoral component. Appropriate placement of the femoral component could significantly reduce a patient’s perception of discrepancy of length.
We compared the outcomes of bilateral total hip arthroplasty performed as a one-stage or two-stage procedure. We retrospectively identified 196 patients (392 hips) with bilateral arthritis of the hip who underwent total hip arthroplasties: 98 patients (196 hips) as a one-stage procedure (one-stage group) and 98 (196 hips) as a two-stage procedure (two-stage group). All patients had uncemented components implanted under spinal anesthesia and had the same postoperative rehabilitation protocol. Both groups' functional outcomes were similar. The mean preoperative hemoglobin was 12.6 g/dL in the one-stage group and 12.9 g/dL in the two-stage group. The mean cumulative blood transfusion was 2.6 units in the one-stage group and 3.5 units in the two-stage group. Patients in the two-stage group had more complications, most commonly anemia and wound drainage. The total mean hospital stay was longer in the two-stage group (8.1 days; range, 5-39 days) compared with the one-stage group (4.3 days; range, 3-11 days). The mean total expenses were higher in the two-stage group (dollar 64,600) compared with the one-stage group (dollar 45,900). Young and healthy patients may be candidates for one-stage bilateral total hip arthroplasty without an increase in complications and with lower costs.
Current concepts review. Lower limb-length discrepancy
- Siffert