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A simple intraoperative technique to avoid limb length discrepancy in total hip arthroplasty
the surgeon 8 (2010) 119–121
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Surgical Technique
A simple intraoperative technique to avoid limb length discrepancy in total hip arthroplasty
Keywords Limb length discrepancy Total hip arthroplasty
Sir,
Introduction Limb length discrepancy (LLD) following total hip arthroplasty (THA) is a well-known and documented complication. LLD can pose a substantial problem for both the patient and the surgeon. Patient dissatisfaction with LLD after THA is the most common reason for litigation against orthopaedic surgeons.1,2 Failure to restore limb length may lead to an unstable hip, whereas over-lengthening may cause low back pain, sciatic nerve palsy and early mechanical loosening.3 Several intraoperative techniques both invasive and noninvasive have been reported in the literature to overcome LLD during THA.2,4–10 The accuracy of all the methods that measure from pins anchored into pelvis to point on the greater trochanter may be affected by the inherent variability of the leg position when measurements are made. Bending or dislodging the pins and using of calliper devices can be cumbersome during the THA surgery and can compromise the measurements. Hence we describe a simple, safe and reliable intraoperative technique, which can be easily used in THA surgery done by posterior approach without any additional equipment, incision and radiographs.
acetabulum into the ileum to retract the abductors anteriorly from the operative site. This forms the stable pelvic reference point. A thread/suture (normally no. 5 ethibond, but any stout braided material can be used) is then securely tied to this pin, and a knot tied into the suture at a length of roughly 10 cm. The operated leg is placed exactly over the top of the contralateral leg, which should be palpable through the drapes by lining up the heels which, is the easy way to reproduce the same attitude of hip flexion as the contralateral leg i.e. contralateral hip in 45 flexion and knee in 90 flexion which makes it easy to place the operating leg over the non-operated leg. Once satisfied that the hip is in this position, a mark is made using diathermy on the greater trochanter to the long axis of the femur, at a point corresponding to the knot in the suture (Fig. 1). This mark is the preoperative leg length, which can then be used as guide intraoperatively to either lengthen or maintain the same length based on preoperative templating/planning. The pin in the ileum is left in place throughout
Materials and methods Operative technique The patient is placed in the lateral position and a posterior approach to the hip used. Prior to dislocation of the hip, a Judd pin (Judd Medical, Braintree, Essex, U.K.) or any other stout retractor pin is inserted into the pelvis just superior to the
Fig. 1 – Judd pin with thread and knot-marking the reference point.
120
the surgeon 8 (2010) 119–121
Fig. 2 – Level of the mark proximal to the knot-limb shortened.
Fig. 5 – Intraoperative photograph showing the level of the mark at the knot-limb length maintained.
shortening is noted pre-operatively then one can aim to achieve length by this mark (Figs. 4 and 5). The final distance between the knot and the mark is recorded as the indication of LLD. The technique is dependant on two factors as described by Bose WJ2 i.e. 1) Ensuring that the Judd pin stays in its original point in the pelvis and is stable. 2) The attitude of the leg when measuring i.e. ensuring that it stays in the same position. Fig. 3 – Level of mark distal to the knot-limb lengthened.
Discussion
Fig. 4 – Level of the mark at the knot-limb length maintained.
the operation and the suture/thread left attached. The suture is rested away from the hip joint. The hip is then dislocated and the arthroplasty performed in the usual way. With the trial components in place, the limb is again placed in the position as described above. The suture attached to the Judd pin is then utilised i.e. the knot is compared to the mark made in the greater trochanter. The level of the mark on the greater trochanter distal or proximal to the knot gives an indication of lengthening or shortening (Figs. 2 and 3). Adjustments can then be made to optimise the leg length i.e. if
It is widely accepted that surgeons performing THA should aim to minimize LLD, and therefore should adopt a reliable method of doing so. The use of a stable pelvic reference, combined with a method for accurately positioning the leg during measurements, provides the surgeon a practical method for measuring leg length during arthroplasty.11 The risk of introducing error in leg length measurement by bending or loosening of the pin in the ileum can be definitely overcome by this simple and reliable technique using a stout Judd pin. Utilising the routine incision for the posterior approach to the hip, this technique can be easily carried out in primary THA surgery as compared to other techniques used to avoid LLD, which require further incision, and specialised equipment which are time consuming, cumbersome and may not be very secure. This technique of using a suture mark over the Judd pin is simple, inexpensive and easily adaptable.
references
1. Hofmann AA, Skrzynski MC. Leg-length inequality and nerve palsy in total hip arthroplasty: a lawyer awaits! Orthopedics 2000;23(9):943–4. 2. Bose WJ. Accurate limb-length equalization during total hip arthroplasty. Orthopedics 2000;23(5):433–6. 3. Amstuz SM, Jinnah RH, Mai L. Revision of aseptic loose total hip arthroplasties. Clin Orthop 1982;170:21–3.
the surgeon 8 (2010) 119–121
4. Charnley J. Low friction arthroplasty of the hip. Berlin, Germany: Springer-Verlag; 1979. 5. Mihalko WM, Phillips MJ, Krackow KA. Acute sciatic and femoral neuritis following total hip arthroplasty: a case report. J Bone Joint Surg Am 2001;83:589–92. 6. Mcgee HMJ, Scott JHS. A simple method of obtaining equal leg length in total hip arthroplasty. Clin Orthop 1985;194:269–70. 7. Bal BS. A technique for comparison of leg lengths during total hip replacement. Am J Orthop 1996;25:61–2. 8. Huddleston HD. An accurate method for measuring leg length and hip offset in hip arthroplasty. Orthopedics 1997;20:331–2. 9. Naito M, Ogata K, Asayama I. Intraoperative limb length measurement in total hip arthroplasty. Int Orthop 1999;23:31–3. 10. Takigami I, Itokazu M, Itoh Y, Matsumoto K, Yamamoto T, Shimizu K. Limb-length measurement in total hip arthroplasty using a calipers dual pin retractor. Bull NYU Hosp Jt Dis 2008;66(2):107–10. 11. Clark CR, Huddleston HD, Schoch EP, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 2006;14:38–45.
121
Aravind Desai*, Bilal Barkatali, Asterios Dramis, Timothy N. Board Centre for Hip Surgery, Wrightington Hospital, Wigan, UK *Correspondence to: Aravind Desai, 297 Lovely Lane, Warrington WA5 0AF, UK. Tel.: þ44 07885994545; fax: þ44 01257253853. E-mail address: [email protected] (A. Desai) Available online xxx
1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.023
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Surgical Technique
A simple intraoperative technique to avoid limb length discrepancy in total hip arthroplasty
Keywords Limb length discrepancy Total hip arthroplasty
Sir,
Introduction Limb length discrepancy (LLD) following total hip arthroplasty (THA) is a well-known and documented complication. LLD can pose a substantial problem for both the patient and the surgeon. Patient dissatisfaction with LLD after THA is the most common reason for litigation against orthopaedic surgeons.1,2 Failure to restore limb length may lead to an unstable hip, whereas over-lengthening may cause low back pain, sciatic nerve palsy and early mechanical loosening.3 Several intraoperative techniques both invasive and noninvasive have been reported in the literature to overcome LLD during THA.2,4–10 The accuracy of all the methods that measure from pins anchored into pelvis to point on the greater trochanter may be affected by the inherent variability of the leg position when measurements are made. Bending or dislodging the pins and using of calliper devices can be cumbersome during the THA surgery and can compromise the measurements. Hence we describe a simple, safe and reliable intraoperative technique, which can be easily used in THA surgery done by posterior approach without any additional equipment, incision and radiographs.
acetabulum into the ileum to retract the abductors anteriorly from the operative site. This forms the stable pelvic reference point. A thread/suture (normally no. 5 ethibond, but any stout braided material can be used) is then securely tied to this pin, and a knot tied into the suture at a length of roughly 10 cm. The operated leg is placed exactly over the top of the contralateral leg, which should be palpable through the drapes by lining up the heels which, is the easy way to reproduce the same attitude of hip flexion as the contralateral leg i.e. contralateral hip in 45 flexion and knee in 90 flexion which makes it easy to place the operating leg over the non-operated leg. Once satisfied that the hip is in this position, a mark is made using diathermy on the greater trochanter to the long axis of the femur, at a point corresponding to the knot in the suture (Fig. 1). This mark is the preoperative leg length, which can then be used as guide intraoperatively to either lengthen or maintain the same length based on preoperative templating/planning. The pin in the ileum is left in place throughout
Materials and methods Operative technique The patient is placed in the lateral position and a posterior approach to the hip used. Prior to dislocation of the hip, a Judd pin (Judd Medical, Braintree, Essex, U.K.) or any other stout retractor pin is inserted into the pelvis just superior to the
Fig. 1 – Judd pin with thread and knot-marking the reference point.
120
the surgeon 8 (2010) 119–121
Fig. 2 – Level of the mark proximal to the knot-limb shortened.
Fig. 5 – Intraoperative photograph showing the level of the mark at the knot-limb length maintained.
shortening is noted pre-operatively then one can aim to achieve length by this mark (Figs. 4 and 5). The final distance between the knot and the mark is recorded as the indication of LLD. The technique is dependant on two factors as described by Bose WJ2 i.e. 1) Ensuring that the Judd pin stays in its original point in the pelvis and is stable. 2) The attitude of the leg when measuring i.e. ensuring that it stays in the same position. Fig. 3 – Level of mark distal to the knot-limb lengthened.
Discussion
Fig. 4 – Level of the mark at the knot-limb length maintained.
the operation and the suture/thread left attached. The suture is rested away from the hip joint. The hip is then dislocated and the arthroplasty performed in the usual way. With the trial components in place, the limb is again placed in the position as described above. The suture attached to the Judd pin is then utilised i.e. the knot is compared to the mark made in the greater trochanter. The level of the mark on the greater trochanter distal or proximal to the knot gives an indication of lengthening or shortening (Figs. 2 and 3). Adjustments can then be made to optimise the leg length i.e. if
It is widely accepted that surgeons performing THA should aim to minimize LLD, and therefore should adopt a reliable method of doing so. The use of a stable pelvic reference, combined with a method for accurately positioning the leg during measurements, provides the surgeon a practical method for measuring leg length during arthroplasty.11 The risk of introducing error in leg length measurement by bending or loosening of the pin in the ileum can be definitely overcome by this simple and reliable technique using a stout Judd pin. Utilising the routine incision for the posterior approach to the hip, this technique can be easily carried out in primary THA surgery as compared to other techniques used to avoid LLD, which require further incision, and specialised equipment which are time consuming, cumbersome and may not be very secure. This technique of using a suture mark over the Judd pin is simple, inexpensive and easily adaptable.
references
1. Hofmann AA, Skrzynski MC. Leg-length inequality and nerve palsy in total hip arthroplasty: a lawyer awaits! Orthopedics 2000;23(9):943–4. 2. Bose WJ. Accurate limb-length equalization during total hip arthroplasty. Orthopedics 2000;23(5):433–6. 3. Amstuz SM, Jinnah RH, Mai L. Revision of aseptic loose total hip arthroplasties. Clin Orthop 1982;170:21–3.
the surgeon 8 (2010) 119–121
4. Charnley J. Low friction arthroplasty of the hip. Berlin, Germany: Springer-Verlag; 1979. 5. Mihalko WM, Phillips MJ, Krackow KA. Acute sciatic and femoral neuritis following total hip arthroplasty: a case report. J Bone Joint Surg Am 2001;83:589–92. 6. Mcgee HMJ, Scott JHS. A simple method of obtaining equal leg length in total hip arthroplasty. Clin Orthop 1985;194:269–70. 7. Bal BS. A technique for comparison of leg lengths during total hip replacement. Am J Orthop 1996;25:61–2. 8. Huddleston HD. An accurate method for measuring leg length and hip offset in hip arthroplasty. Orthopedics 1997;20:331–2. 9. Naito M, Ogata K, Asayama I. Intraoperative limb length measurement in total hip arthroplasty. Int Orthop 1999;23:31–3. 10. Takigami I, Itokazu M, Itoh Y, Matsumoto K, Yamamoto T, Shimizu K. Limb-length measurement in total hip arthroplasty using a calipers dual pin retractor. Bull NYU Hosp Jt Dis 2008;66(2):107–10. 11. Clark CR, Huddleston HD, Schoch EP, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 2006;14:38–45.
121
Aravind Desai*, Bilal Barkatali, Asterios Dramis, Timothy N. Board Centre for Hip Surgery, Wrightington Hospital, Wigan, UK *Correspondence to: Aravind Desai, 297 Lovely Lane, Warrington WA5 0AF, UK. Tel.: þ44 07885994545; fax: þ44 01257253853. E-mail address: [email protected] (A. Desai) Available online xxx
1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.023