Advertisement

A low-volume surgeon is an independent risk factor for leg length discrepancy after primary total hip arthroplasty: a case-control study

  • Yuji KishimotoEmail author
  • Hiroko Suda
  • Takahiro Kishi
  • Toshiaki Takahashi
Original Paper
  • 27 Downloads

Abstract

Purpose

Leg length discrepancy (LLD) is one of the bothersome complications that reduce patient satisfaction after total hip arthroplasty (THA). This study aimed to investigate the independent risk factors of LLD after primary THA.

Methods

This is a case-control study of 163 THAs for 163 patients at our institution between April 2015 and March 2018. The relevant data about the general characteristics of the patients (age, sex, body mass index, and diagnosis), surgery (surgical approach, type of femoral stem fixation, and surgeon volume), and radiological findings (Dorr classification and pre-operative LLD) were reviewed to identify the risk factors of ≥ 5 mm post-operative LLD according to radiological measurement and to calculate odds ratios (OR) via logistic regression analysis.

Results

The median (interquartile) absolute value of post-operative LLD was 3.9 (2.3–7.4) mm, and 57 (35.0%) patients had LLD of ≥ 5 mm. After controlling for possible confounders, a low-volume surgeon was considered the only independent risk factor of post-operative LLD (adjusted OR: 8.26; 95% confidence interval: 3.48, 19.60; P < 0.001). Among the 103 patients performed by high-volume surgeons, 82 (79.6%) had LLD of < 5 mm, whereas among the 60 patients performed by low-volume surgeons, only 24 (40.0%) achieved LLD of < 5 mm (P < 0.001).

Conclusion

A low-volume surgeon is associated with an increased risk of a post-operative LLD after primary THA, and the importance of measurements should be recognized to prevent post-operative LLD and achieve optimal outcomes. Moreover, surgeons must inform patients about the risk of developing LLD pre-operatively.

Keywords

Primary total hip arthroplasty Leg length discrepancy Surgeon volume 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Flecher X, Ollivier M, Argenson JN (2016) Lower limb length and offset in total hip arthroplasty. Orthop Traumatol Surg Res 102(1 Suppl):S9–S20.  https://doi.org/10.1016/j.otsr.2015.11.001 CrossRefPubMedGoogle Scholar
  2. 2.
    Roder C, Vogel R, Burri L, Dietrich D, Staub LP (2012) Total hip arthroplasty: leg length inequality impairs functional outcomes and patient satisfaction. BMC Musculoskelet Disord 13:95.  https://doi.org/10.1186/1471-2474-13-95 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Wylde V, Whitehouse SL, Taylor AH, Pattison GT, Bannister GC, Blom AW (2009) Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement. Int Orthop 33(4):905–909.  https://doi.org/10.1007/s00264-008-0563-6 CrossRefPubMedGoogle Scholar
  4. 4.
    Plaass C, Clauss M, Ochsner PE, Ilchmann T (2011) Influence of leg length discrepancy on clinical results after total hip arthroplasty--a prospective clinical trial. Hip Int 21(4):441–449.  https://doi.org/10.5301/HIP.2011.8575 CrossRefPubMedGoogle Scholar
  5. 5.
    Novi M, Vanni C, Parchi PD, Di Paolo M, Piolanti N, Scaglione M (2019) Claims in total hip arthroplasty: analysis of the instigating factors, costs and possible solution. Musculoskelet Surg.  https://doi.org/10.1007/s12306-019-00590-6
  6. 6.
    Samuel LT, Sultan AA, Rabin JM, Surace PA, Yao B, Moskal JT, Mont MA (2019) Medical malpractice litigation following primary total joint arthroplasty: a comprehensive, nationwide analysis of the past decade. J Arthroplast.  https://doi.org/10.1016/j.arth.2019.02.066
  7. 7.
    Lim YW, Huddleston JI 3rd, Goodman SB, Maloney WJ, Amanatullah DF (2018) Proximal femoral shape changes the risk of a leg length discrepancy after primary total hip arthroplasty. J Arthroplast.  https://doi.org/10.1016/j.arth.2018.08.008
  8. 8.
    Brumat P, Pompe B, Antolic V, Mavcic B (2018) The impact of canal flare index on leg length discrepancy after total hip arthroplasty. Arch Orthop Trauma Surg 138(1):123–129.  https://doi.org/10.1007/s00402-017-2840-6 CrossRefPubMedGoogle Scholar
  9. 9.
    Kennedy JW, Young D, Meek DRM, Patil SR (2018) Obesity is associated with higher complication rates in revision total hip arthroplasty. J Orthop 15(1):70–72.  https://doi.org/10.1016/j.jor.2018.01.018 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 12(12):1495–1499.  https://doi.org/10.1016/j.ijsu.2014.07.013 CrossRefGoogle Scholar
  11. 11.
    Sykes A, Hill J, Orr J, Humphreys P, Rooney A, Morrow E, Beverland D (2015) Patients’ perception of leg length discrepancy post total hip arthroplasty. Hip Int 25(5):452–456.  https://doi.org/10.5301/hipint.5000276 CrossRefPubMedGoogle Scholar
  12. 12.
    Renkawitz T, Weber T, Dullien S, Woerner M, Dendorfer S, Grifka J, Weber M (2016) Leg length and offset differences above 5 mm after total hip arthroplasty are associated with altered gait kinematics. Gait Posture 49:196–201.  https://doi.org/10.1016/j.gaitpost.2016.07.011 CrossRefPubMedGoogle Scholar
  13. 13.
    Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH (1993) Structural and cellular assessment of bone quality of proximal femur. Bone 14(3):231–242CrossRefGoogle Scholar
  14. 14.
    Ravi B, Jenkinson R, Austin PC, Croxford R, Wasserstein D, Escott B, Paterson JM, Kreder H, Hawker GA (2014) Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study. BMJ 348:g3284.  https://doi.org/10.1136/bmj.g3284 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Leucht P, Huddleston HG, Bellino MJ, Huddleston JI (2015) Does intraoperative fluoroscopy optimize limb length and the precision of acetabular positioning in primary THA? Orthopedics 38(5):e380–e386.  https://doi.org/10.3928/01477447-20150504-54 CrossRefPubMedGoogle Scholar
  16. 16.
    Vittinghoff E, McCulloch CE (2007) Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 165(6):710–718.  https://doi.org/10.1093/aje/kwk052 CrossRefPubMedGoogle Scholar
  17. 17.
    Scarlat MM, Pecina M, Quaile A (2018) High-volume surgeons and high-volume journals in a multivariate orthopedic environment. Int Orthop 42(9):2011–2014.  https://doi.org/10.1007/s00264-018-4073-x CrossRefPubMedGoogle Scholar
  18. 18.
    Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA (2001) Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am 83-A(11):1622–1629CrossRefGoogle Scholar
  19. 19.
    Kaneko T, Hirakawa K, Fushimi K (2014) Relationship between peri-operative outcomes and hospital surgical volume of total hip arthroplasty in Japan. Health Policy 117(1):48–53.  https://doi.org/10.1016/j.healthpol.2014.03.013 CrossRefPubMedGoogle Scholar
  20. 20.
    Yasunaga H, Tsuchiya K, Matsuyama Y, Ohe K (2009) High-volume surgeons in regard to reductions in operating time, blood loss, and postoperative complications for total hip arthroplasty. J Orthop Sci 14(1):3–9.  https://doi.org/10.1007/s00776-008-1289-4 CrossRefPubMedGoogle Scholar
  21. 21.
    Losina E, Barrett J, Mahomed NN, Baron JA, Katz JN (2004) Early failures of total hip replacement: effect of surgeon volume. Arthritis Rheum 50(4):1338–1343.  https://doi.org/10.1002/art.20148 CrossRefPubMedGoogle Scholar
  22. 22.
    Glassou EN, Hansen TB, Makela K, Havelin LI, Furnes O, Badawy M, Karrholm J, Garellick G, Eskelinen A, Pedersen AB (2016) Association between hospital procedure volume and risk of revision after total hip arthroplasty: a population-based study within the Nordic Arthroplasty Register Association database. Osteoarthr Cartil 24(3):419–426.  https://doi.org/10.1016/j.joca.2015.09.014 CrossRefPubMedGoogle Scholar
  23. 23.
    Barrack RL, Krempec JA, Clohisy JC, McDonald DJ, Ricci WM, Ruh EL, Nunley RM (2013) Accuracy of acetabular component position in hip arthroplasty. J Bone Joint Surg Am 95(19):1760–1768.  https://doi.org/10.2106/JBJS.L.01704 CrossRefPubMedGoogle Scholar
  24. 24.
    Loweg L, Kutzner KP, Trost M, Hechtner M, Drees P, Pfeil J, Schneider M (2018) The learning curve in short-stem THA: influence of the surgeon’s experience on intraoperative adjustments due to intraoperative radiography. Eur J Orthop Surg Traumatol 28(2):269–275.  https://doi.org/10.1007/s00590-017-2049-y CrossRefPubMedGoogle Scholar
  25. 25.
    Romanowski JR, Swank ML (2008) Imageless navigation in hip resurfacing: avoiding component malposition during the surgeon learning curve. J Bone Joint Surg Am 90(Suppl 3):65–70.  https://doi.org/10.2106/JBJS.H.00462 CrossRefPubMedGoogle Scholar
  26. 26.
    Nistor DV, Caterev S, Bolboaca SD, Cosma D, Lucaciu DOG, Todor A (2017) Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon? Int Orthop 41(11):2245–2252.  https://doi.org/10.1007/s00264-017-3480-8 CrossRefPubMedGoogle Scholar
  27. 27.
    Nossa JM, Munoz JM, Riveros EA, Rueda G, Marquez D, Perez J (2018) Leg length discrepancy after total hip arthroplasty: comparison of 3 intraoperative measurement methods. Hip Int 28(3):254–258.  https://doi.org/10.5301/hipint.5000577 CrossRefPubMedGoogle Scholar
  28. 28.
    Ellapparadja P, Mahajan V, Atiya S, Sankar B, Deep K (2016) Leg length discrepancy in computer navigated total hip arthroplasty - how accurate are we? Hip Int 26(5):438–443.  https://doi.org/10.5301/hipint.5000368 CrossRefPubMedGoogle Scholar
  29. 29.
    Lecoanet P, Vargas M, Pallaro J, Thelen T, Ribes C, Fabre T (2018) Leg length discrepancy after total hip arthroplasty: can leg length be satisfactorily controlled via anterior approach without a traction table? Evaluation in 56 patients with EOS 3D. Orthop Traumatol Surg Res 104(8):1143–1148.  https://doi.org/10.1016/j.otsr.2018.06.020 CrossRefPubMedGoogle Scholar
  30. 30.
    Zhang Y, He W, Cheng T, Zhang X (2015) Total hip arthroplasty: leg length discrepancy affects functional outcomes and patient’s gait. Cell Biochem Biophys 72(1):215–219.  https://doi.org/10.1007/s12013-014-0440-4 CrossRefPubMedGoogle Scholar
  31. 31.
    Heaver C, St Mart JP, Nightingale P, Sinha A, Davis ET (2013) Measuring limb length discrepancy using pelvic radiographs: the most reproducible method. Hip Int 23(4):391–394.  https://doi.org/10.5301/hipint.5000042 CrossRefPubMedGoogle Scholar
  32. 32.
    Sabharwal S, Kumar A (2008) Methods for assessing leg length discrepancy. Clin Orthop Relat Res 466(12):2910–2922.  https://doi.org/10.1007/s11999-008-0524-9 CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Schmidutz F, Beirer M, Weber P, Mazoochian F, Fottner A, Jansson V (2012) Biomechanical reconstruction of the hip: comparison between modular short-stem hip arthroplasty and conventional total hip arthroplasty. Int Orthop 36(7):1341–1347.  https://doi.org/10.1007/s00264-011-1477-2 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© SICOT aisbl 2019

Authors and Affiliations

  1. 1.Department of RheumatologyTottori Red Cross HospitalTottoriJapan
  2. 2.Department of Orthopedic SurgeryTottori Red Cross HospitalTottoriJapan

Personalised recommendations