McKinnis_Ch12_001-001 11/07/14 1:45 PM Page 1
●
Focus On
Leg Length Outcome After Total Hip
Arthroplasty
Total hip arthroplasty (THA) procedures produce stability in
the joint, in part by creating soft-tissue tension in muscles and
ligaments around the hip. This softening can sometimes result
in leg lengthening.1 Additionally, the choice of placement of
the prosthetic components by the surgeon is limited, with little
room to maneuver, which can sometimes result in leg short-
ening. The alignment of the affected leg is more valgus than
the unaffected leg before arthroplasty but tends toward varus
after THA. The discrepancy between the lower limb align-
ments on both sides may also increase or decrease after THA.2
A recent study assessed the rate of self-perceived (versus
radiologically documented) leg length discrepancies (LLDs)
in a population-based cohort 6 years after THA and found
that 32% of the subjects perceived an LLD. These results were
compared with data from prior literature, which reported
radiographically documented LLD that varied on average be-
tween 1 and 16 mm, with the perceived LLD falling between
6% and 32%.3
The risk for leg length inequality has been reported as
6% for primary replacements and 7.5% for revision replace-
ments.4 These figures include both true leg length discrepancy
and apparent, or functional, leg length discrepancy.
Additionally, preexisting soft-tissue tension, such as a fixed
adduction contracture, may give the perception of leg length
inequality without true limb shortening.5 This usually resolves
in 6 weeks to several months with stretching exercises.5
True statistics are hard to determine, because no consensus
exists regarding the definition of a significant postoperative
inequality. The reported incidences range widely from 5% to
almost 95%, based on the definition of leg length inequality.5
Some physicians use variable quantity, perhaps accepting as
much as 2 cm, whereas others define leg length discrepancy
only when patients experience adverse functional gait.5
Copyright © 2014. F.A. Davis Company
Studies have examined patient dissatisfaction with leg
length inequality following THA with mixed results. Re-
searchers in Scotland concluded that there is no statistical
association between length inequality following THA and
functional outcome or patient satisfaction.6 Other studies,
however, noted significant gait disturbance, with limping and
patient discomfort, due to this issue.5,7
Researchers are addressing the need for means to reduce the
problem.8 Current recommendations are that the surgeon
should not rely on templating alone but also use intraoperative
testing and/or measurement and preoperative assessment of
LLDs with radiographs. When using preoperative templating to
assess for LLDs, using the interteardrop line and center of the
femoral head is preferred. This has proven to provide the most
accurate measurement of a LLD compared with the true LLD
measured on standing anteroposterior full-leg radiographs.8
References
1. DeSmet K: The total hip replacement. ANCA-Clinic for Hip Surgery, Heusden,
Belgium, 2003. Available at: http://www.hip-clinic.com/en/hip-info/treatment/
total-hip-replacement. Accessed October 4, 2004.
2. Fujimaki H, Inaba Y, Kobayashi N, Tezuka T, Hirata Y, Saito T: Leg length
discrepancy and lower limb alignment after total hip arthroplasty in unilateral
hip osteoarthritis patients. J Orthop Sci [Epub ahead of print], August 21,
2013.
3. Iversen MD, Chudasama N, Losina E, Katz JN: Influence of self reported
leg length discrepancy on function and satisfaction 6 years after total hip
replacement. J Geriatr Phys Ther 34(3):148–152, 2011.
4. Villar R: Understanding Hip and Knee Arthritis Surgery, 3rd ed. Poole, UK:
Family Doctor Books, 2008.
5. Roder C, Vogel R, Burri L, Dietrich D, Staub LP: Total hip arthroplasty: Leg
length inequality impairs functional outcomes and patient satisfaction. BMC
Musculoskelet Disord 13:95, 2012.
6. White TO, Dougall TW: Arthroplasty of the hip: Leg length is not important.
J Bone Joint Surg Br 84(3):335–338, 2002.
7. Boisgard S, et al: Bone reconstruction, leg length discrepancy, and dislocation
rate in 52 Wagner revision total hip arthroplasties at 44-month follow-up. Rev
Chir Orthop Reparatrice Appar Mot 87(2):147–154, 2001.
8. Meermans G, Malik A, Witt J, Haddad F: Preoperative radiographic assess-
ment of limb-length discrepancy in total hip arthroplasty. Clin Orthop Relat
Res 469(6):1677–1682, 2011.