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