n guest editorial
Limb-length Discrepancy After Total Hip Arthroplasty Steven F. Harwin, MD, FACS; Robert Pivec, MD
imb-length discrepancy, to one degree or another, is a problem that must be reckoned with after total hip arthroplasty (THA). It must be addressed as both a clinical issue for patients and, unfortunately, a potential medicolegal problem. Although a small limb-length discrepancy may cause no symptoms or may not be perceived, a large limb-length discrepancy may cause nerve palsy, low back pain, altered gait, hip instability, and patient dissatisfaction.1-4 Importantly, limb-length discrepancy is believed to be the leading cause of malpractice claims after THA.5-7 Despite deliberate attempts to equalize leg lengths using meticulous preoperative planning and intraoperative guides, landmarks, and navigation, limb-length discrepancy of 1 cm or more is common. Most often there is only minimal influence on function, but larger discrepancies are associated with inferior functional outcomes and lower patient satisfaction rates.8 In this issue of Orthopedics, Thakral et al describe a novel technique for correcting limb-length discrepancy after THA using distraction osteogenesis of the contralateral limb. Although this is an interesting study, it should be considered preliminary work, with its main limitation being its small sample. It is hoped that this will generate interest in this technique and additional, larger studies. It is encouraging that all patients were able to return to their activities of daily living and reported improved The authors are from the Adult Reconstruction and Total Joint Replacement Service (SFH), Mount Sinai Health Care System, Beth Israel Medical Center, New York, New York; and the Center for Joint Preservation and Replacement (RP), Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Steven F. Harwin, MD, FACS, Chief, Adult Reconstruction and Total Joint Replacement Service, Mount Sinai Health Care System, Beth Israel Medical Center, 910 Park Ave, New York, NY 10075 ([email protected]
). doi: 10.3928/01477447-20140124-04
satisfaction once the limb-length discrepancy was corrected. In addition, Thakral et al provide a thorough discussion of all aspects of limb-length discrepancy along with a suggested treatment algorithm for surgeons performing THA. Symptomatic limb-length discrepancy after THA is a challenging condition to treat. Nonsurgical measures such as physical therapy or shoe lifts can treat discrepancies of less than 1 cm. Correcting larger discrepancies, such as those greater than 2 cm, typically requires invasive surgical procedures. Options include revision THA, ipsilateral limb shortening, or contralateral THA.9-11 Each of these techniques has drawbacks, such as low patient compliance with using shoe lifts. A small lift can be placed inside the shoe, but larger ones must be on the outside and may be unsightly. Obviously, when shoes are removed, the limb-length discrepancy returns. Revision of the ipsilateral hip to correct limb-length discrepancy is not desirable in cases where there is no evidence of prosthetic dysfunction and the lack of substantial arthritis in the contralateral hip may rule out primary THA to gain length. Thakral et al provide an option for patients who may not want to wear shoe lifts, who have well-fixed ipsilateral prostheses, and who have no evidence of advanced arthritis in the contralateral hip. Thakral et al correctly point out that not all patients may be candidates for their procedure to correct limb-length discrepancy after THA, and they offer a treatment algorithm for the problem. They propose a novel technique for the correction of limb-length discrepancy that has not been previously reported and are to be commended for their research and study.
References 1. Edeen J, Sharkey PF, Alexander AH. Clinical significance of leg-length inequality after total hip arthroplasty. Am J Orthop (Belle Mead NJ). 1995; 24(4):347-351.
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2. Clark CR, Huddleston HD, Schoch EP III, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg. 2006; 14(1):38-45. 3. Abraham WD, Dimon JH III. Leg length discrepancy in total hip arthroplasty. Orthop Clin North Am. 1992; 23(2):201-209. 4. Mihalko WM, Phillips MJ, Krackow KA. Acute sciatic and femoral neuritis following total hip arthroplasty: a case report. J Bone Joint Surg Am. 2001; 83(4):589-592. 5. Upadhyay A, York S, Macaulay W, McGrory B, Robbennolt J, Bal BS. Medical malpractice in hip and knee arthroplasty. J Arthroplasty. 2007; 22(6 suppl 2):2-7. 6. Gidwani S, Zaidi SM, Bircher MD. Medical negligence in orthopaedic surgery: a review of 130 consecutive medical negligence reports. J Bone Joint Surg Br. 2009; 91(2):151-156.
7. Attarian DE, Vail TP. Medicolegal aspects of hip and knee arthroplasty. Clin Orthop Relat Res. 2005; (433):72-76. 8. Bhave A, Paley D, Herzenberg JE. Improvement in gait parameters after lengthening for the treatment of limb-length discrepancy. J Bone Joint Surg Am. 1999; 81(4):529-534. 9. Pritchett JW. Nerve injury and limb lengthening after hip replacement: treatment by shortening. Clin Orthop Relat Res. 2004; (418):168-171. 10. Kasis AG, Stockley I, Saleh M. External fixator-assisted acute shortening with internal fixation for leg length discrepancy after total hip replacement. Strategies Trauma Limb Reconstr. 2008; 3(1):35-38. 11. Golightly YM, Tate JJ, Burns CB, Gross MT. Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report. J Orthop Sports Phys Ther. 2007; 37(7):380-388.
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