Jan 03, 2016
introduction Is it a true concern ? depends on :
value Origin preoperative status patient expectation. surgeon priority
Arthroplasty of the hip. Leg length is not important. JBJS Br. 2002 Apr;84(3):335-8. White TO, Dougall TW
But an actual problem for the surgeon and his patient
?
introduction
frequency frequent under 10 mm in the literature
Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement.
Int Orthop. 2008 Apr 25 Wylde V, Whitehouse SL : 30% (1114 hips)
Revision >primary
personal experience 2 LLD > 10 mm in revision cases None case during primary surgery usual accuracy < 5 mm in 90% of cases more often lengthening than shortening
anatomical basisTrue segmental LLD
acetabular side femoral side
False segmental LLD Spinal origin (fixed deformity with pelvic
obliquity) other length discrepancy in the bone segments
or joints under the hip
In all cases, a mistake for the patient
diagnosisclinical examination:
limb length measurement range of motion
stiffnessfixed abduction
radiological examination Pelvic AP radiograph in a standing position long standing view in a standing position
causesPreoperative causes
lack or bad preoperative planning bad assessment of other parameters (spine, bone
segments)
intraoperative causes acetabular side
high position too horizontal inclination lack of impaction : lateralization
femoral side neck resection levelchoice of the prosthesis neck length
consequences lateral hip pain, trochanteric pain
muscle weakness or tightness (lack of motion)
Limping
back pain
knee pain (homo or contra lateral)
limb nerve damage : pain, palsy
radiculopathy
loosening The role of overlength of the leg in aseptic loosening after total hip
arthroplasty. Ital J Orthop Traumatol. 1993;19(1):107-11. Visuri T, Lindholm TS, Antti-Poika I, Koskenvuo M
TreatmentShoe lift
femoral diaphysis shortening
Revision uni or bipolar be careful , shortening expose to postoperative
instability, lowering of the greater trochanter helps to prevent it
How to prevent LLDpreoperative planning PO
standard templating
Magnification is the problem
How to prevent LLDpreoperative planning PO
standard templating : complex cases
How to prevent LLD preoperative planning PO
digitalized planning (Bfits Biomet)
if preoperative discrepancy, it must be calculated on a standard planning
How to prevent LLDAnatomical references
acetabular inferior margin lesser trochanter
Great trochanter summit Soft tissue tension contra lateral limb
????
How to prevent LLD Intraoperative measurement
superposition of the trial femoral prosthesis with the femoral neck along with the femoral axis and according to the preoperative planning
How to prevent LLD Intraoperative measurement
Measurement of the resected neck according to the PO
Calliper and Carpenter Level
P Chiron
How to prevent LLD Intraoperative measurement
Measurement of the trochanteric-iliac distance Calliper and Carpenter Level
How to prevent LLD Intraoperative measurement
ultrasonographic measurement intraoperative radioscopy
How to prevent LLDComputer Assisted Surgery
LLD 0.6 +/- 3 mm (range -5 to 10 mm) [Computer-assisted positioning of the acetabular
cup for total hip arthroplasty based on joint kinematics without prior imaging: preliminary results with computed tomographic assessment]
RCO. 2006 Jun;92(4):316-25.Laffargue P, Pinoit Y, Tabutin J, Giraud F, Puget J,
Migaud H.
conclusion frequent but often well tolerated after 6 months if less than 1
cm
Acute preoperative planning (PP) still is the simplest way to avoid major LLD (digitalized PP is more reliable)
Intraoperative references may help to check the data coming from the PP, but can not replace it
CAS definitely helps to minimize LLD to a very low level
Do not forget to inform the patient (before and ….after surgery)
I still need to paid attention to this issue even after several thoousand THA
Thank you for your attention