LIMB-LENGTH DISCREPANCY

Ideally, the leg lengths should be equal after total hip arthroplasty, but it may be difficult to
determine this accurately at the time of surgery. Over lengthening is more common than
shortening, and a lengthened limb is more poorly tolerated. Lengthening may result from
insufficient resection of bone from the femoral neck, use of a prosthesis with a neck that is too
long, or inferior displacement of the center of rotation of the acetabulum (Fig. 3-104). In a
survey of 1114 primary total hip arthroplasty patients, 30% reported a perceived limb length
discrepancy. Of these, only 36% were radiographically confirmed.

The functional significance of leg-length inequality after total hip arthroplasty has not yet been
well defined. Leg lengthening of more than approximately 1 cm frequently is a source of
significant patient dissatisfaction despite an otherwise technically satisfactory operation, and the
commonly used hip rating systems vastly underestimate the degree of dissatisfaction. If
lengthening exceeds 2.5 cm, sciatic palsy and a vaulting-type gait may result.

The risk of excessive leg lengthening can be minimized by a combination of careful

preoperative planning and operative technique. Edeen et al. found that clinical measurements of
leg lengths correlated with radiographic measurements to within 1 cm in only 50% of patients.
Flexion and adduction contractures produce apparent shortening of the extremity and abduction
contracture, although less common, produces apparent lengthening. True bony discrepancies
sometimes require surgical correction, whereas apparent discrepancies arising from contracture
must be recognized, but seldom require extensive soft-tissue release. A history of previous lower
extremity trauma should be sought, and the extremities should be examined for differences
below the level of the hip. Good-quality radiographs and templates of known magnification (see
discussion of preoperative templating in the section on preoperative radiographs) are used to
select a prosthesis that allows intraoperative restoration of leg length and femoral offset.

Several clinical methods for determining leg length have been described. One method involves
intraoperative evaluation of soft-tissue tension around the hip, commonly referred to as the
“shuck test.” When traction is applied to the limb with the hip in extension, distraction of 2 to 4
mm usually occurs. The extent of soft-tissue release, the type of anesthesia, and the degree of
muscular relaxation may change the surgeon’s appreciation of tissue laxity. In addition, soft-
tissue tension depends not only on the height of the femoral head but also on the femoral offset
(see Fig. 3-6). If femoral offset has been reduced and is not appreciated at surgery, tissue tension
has to be restored by inadvertent over lengthening of the limb; in effect, height is substituted for
offset to place the soft tissues under tension. Careful preoperative templating should alert the
surgeon to this possibility, and arrangements should be made for implants that allow
reproduction of the patient’s natural offset and appropriate soft-tissue tensioning without over
lengthening of the limb. Although the assessment of soft-tissue tension is a useful maneuver, it
alone should not be relied on to determine limb length equality.

Multiple methods of limb-length determination have been described using transosseous pins
placed above and below the hip joint and a measuring device. Ranawat et al. used a pin below
the infracotyloid groove and measured the distance between it and a mark on the greater
trochanter. This technique resulted in an average limb-length discrepancy of 1.9 mm, with no
patient requiring a shoe lift (Fig. 3-105). These techniques depend on precise repositioning of
the limb in the same degree of flexion, abduction, and rotation for each measurement. Using a
carpenter’s level to reproduce the positioning of the limb, Bose found an average 3.4-mm limb
length discrepancy in a group of 58 patients, 7% of whom required a shoe lift.

Currently, the most reliable method of equalizing leg lengths is the combination of preoperative
templating and intraoperative measurement. Using this approach in a series of 84 hips, Woolson
et al. reported that only 2.5% of patients had legs that were lengthened more than 6 mm. In a
study of the usefulness and accuracy of preoperative planning, Knight and Atwater concluded
that femoral and acetabular component size could not be predicted reliably by templating;
however, when templating was combined with operative measurement, the postoperative leg
length was within 5 mm of the planned degree of lengthening in 92% of patients.

Computer-assisted techniques may hold promise in achieving limb-length equality after total
hip arthroplasty. Although some studies have shown more accurate reproduction of equal limb
lengths, others have found little or no difference when compared with manual techniques. Also,
functional outcomes to date are not improved by use of computer navigation. Increased cost and
longer operative times have limited the widespread adaptation of computer assisted techniques.

If both hips are diseased and bilateral staged surgery is expected, length is determined by the
stability of the hip, and leg lengths are equalized by making the same bony resections and using
the same implants on both sides. The patient should be advised that a shoe lift may be required
between surgeries. Occasionally, arthroplasty may be indicated in a hip that is already longer
than the contralateral side. Shortening of the limb by excessive neck resection or use of a
prosthesis with a neck that is too short poses the risk of dislocation because of inadequate soft-
tissue tension or impingement. In this instance, distal transfer of the greater trochanter or
shortening by a subtrochanteric osteotomy may be considered.

The main objectives of total hip arthroplasty are, in order of priority, pain relief, stability,
mobility, and equal leg length. The patient should be informed before surgery that no assurance
can be given that the limb lengths will be equal. If lengthening of the limb provides a
substantially more stable hip, the discrepancy is preferable to the risk of recurrent dislocation.
Discrepancies of less than 1 cm generally are well tolerated, and the perception of the
discrepancy tends to diminish with time. Apparent leg-length inequality and pelvic obliquity
caused by residual soft-tissue contracture usually respond to physical therapy with appropriate
stretching.

Patients with an unacceptable limb-length discrepancy must be evaluated carefully to determine

the cause of the discrepancy if surgical treatment is to be successful. Pelvic radiographs are
evaluated for component placement that may cause limb-length discrepancy, such as an
inferiorly placed acetabular component below the teardrop or a proximally placed femoral
component with insufficient neck resection. Parvizi et al. described limb-length discrepancy
caused by acetabular component malpositioning and subsequent instability which had been
accommodated by overlengthening with the modular femoral head. In their group of patients
surgically treated for limb-length discrepancy, most required revision of a maloriented
acetabular component placed inferior to the teardrop or excessively anteverted (20 degrees),
retroverted, or abducted (50 degrees). Limb lengths were equalized in 15 of the 21 patients, with
the average limblength discrepancy decreasing from 4 cm to 1 cm. Only one patient developed
recurrent instability, whereas three patients with pain secondary to neurapraxia had complete
resolution of their symptoms