What is the lower limb length discrepancy after arthroplasty for proximal femoral fracture? A prospective, multicenter observational study of 590 hips

Fredson Razanabola; Henri-Antoine Peuchot; Roger Erivan; Xavier Flecher; Marie Pierret; Hervé Nieto; Christophe Chantelot; Mehdi Hormi-Menard; Benoît Villain; Pierre Martz; François Loubignac; Olivier Gastaud; Régis Bernard de Dompsure; Anthony Viste; Philippe Boisrenoult; Erwan Pansard; Pierre Klein; Romain Rey; Alain Duhamel; Henri Migaud; SoFCOT

doi:10.1016/j.otsr.2024.104119

What is the lower limb length discrepancy after arthroplasty for proximal femoral fracture? A prospective, multicenter observational study of 590 hips

Orthop Traumatol Surg Res. 2024 Dec 20:104119. doi: 10.1016/j.otsr.2024.104119. Online ahead of print.

Authors

Fredson Razanabola¹, Henri-Antoine Peuchot², Roger Erivan³, Xavier Flecher², Marie Pierret⁴, Hervé Nieto⁵, Christophe Chantelot⁶, Mehdi Hormi-Menard⁶, Benoît Villain⁷, Pierre Martz⁸, François Loubignac⁹, Olivier Gastaud¹⁰, Régis Bernard de Dompsure¹¹, Anthony Viste¹², Philippe Boisrenoult¹³, Erwan Pansard¹⁴, Pierre Klein¹⁵, Romain Rey¹⁶, Alain Duhamel¹⁷, Henri Migaud⁶; SoFCOT¹⁸

Affiliations

¹ CHU Orléans, Hôpital La Source, Service de chirurgie Orthopédique et Traumatologique, 14 avenue de l'hôpital, CS 86 709, 45100 Orléans, France.
² Institut du Mouvement et de l'appareil Locomoteur, Département de Chirurgie Orthopédique, Université Aix-Marseille, Hôpital Sainte-Marguerite, 270 Boulevard Sainte-Marguerite, 13009 Marseille, France.
³ Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, ICCF, F-63000 Clermont-Ferrand, France. Electronic address: r.erivan@chu-clermontferrand.fr.
⁴ Höpitaux Civils de Colmar, Service d'Orthopédie Traumatologie, Hôpital Louis Pasteur, 39 Avenue de la Liberté, 68024 Colmar, France.
⁵ Centre Hospitalier de Niort, 40 avenue Charles de Gaulle, 79021 Niort, France.
⁶ Université de Lille, CHRU de Lille, Hôpital Salengro, Service d'Orthopédie - Traumatologie, Av du Pr Emile-Laine, 59000 Lille, France.
⁷ CHU Antoine-Béclère, AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France.
⁸ CHU Dijon, Hôpital François Mitterrand, 2 boulevard Maréchal de Lattre de Tassigny, 21079 Dijon, France.
⁹ Centre Hospitalier Intercommunal Toulon-la Seyne/mer (CHITS), Service de chirurgie orthopédique et traumatologique, Hôpital Sainte-Musse, 4, avenue Sainte-Claire Deville, 83056 Toulon Cedex, France.
¹⁰ Centre Hospitalier de Cannes Simone Veil, Service de Chirurgie Orthopédique et Traumatologique, 15 Avenue des Broussailles, 06401 Cannes, France.
¹¹ CHU de Nice, Hôpital Pasteur, 30 voie Romaine, 06100 Nice, France.
¹² CHU Lyon Sud, 165 chemin du Grand Revoyet, 69495 Oullins-Pierre-Bénite, France.
¹³ Centre Hospitalier de Versailles, Service de chirurgie Orthopédique et Traumatologique, 177 rue de Versailles, 78150 Le Chesnay, France.
¹⁴ CHU Paris Ouest, Hôpital Ambroise Paré, AP-HP, 9 Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France.
¹⁵ Hôpitaux Universitaires de Strasbourg, Service de chirurgie orthopédique et de traumatologie, Hôpital de Hautepierre, 1, Avenue Molière, 67098 Strasbourg, France.
¹⁶ Centre Hospitalier de Dieppe, Avenue Pasteur, 76200 Dieppe, France.
¹⁷ Université de Lille, CHU Lille, ULR2694 METRICS : évaluation des technologies de santé et des pratiques médicales, F59000 Lille, France.
¹⁸ Société Française de Chirurgie Orthopédique et Traumatologique, 56 rue Boissonade, 75014 Paris Cedex, France.

PMID: 39710253
DOI: 10.1016/j.otsr.2024.104119

Abstract

Introduction: Lower limb length discrepancy (LLD) following hip arthroplasty after proximal femoral fracture (PFFA) is little studied. The aim of this work was to answer the following questions: 1) What are the incidence and mean values of LLD after PFFA? 2) What are the clinical consequences (tolerance) of LLD after PFFA? 3) Can we identify risk factors for LLD after PFFA? 4) Is there a significant difference in terms of LLD after PFFA to treat intra- versus extra-capsular fractures?

Hypothesis: LLD after proximal femoral fracture arthroplasty is rare but has good clinical tolerance, given the low functional demands of the patients.

Patients and methods: This is a multicenter prospective observational cohort study (15 centers), including 590 patients, operated on for hip arthroplasty for proximal femur fracture between May 2022 and June 2023. The mean age was 81.74 years (±10.72). The clinical and radiological measurement of LLD was carried out between the 6th week and the 6th month postoperatively. A positive LLD meant that the operated side was lengthened, a negative LLD meant that it was shortened. Clinical tolerance was measured using objective (Merle d'Aubigné (PMA) and Harris (HHS)) and subjective (Oxford-12 and Forgotten Joint Score (FJS)) functional scores as well as autonomy measured using the Parker score.

Results: Clinical and radiological measurements of LLD were highly correlated (p < 0.001), and showed an overall shortening trend of -0.03 mm (±4.99). In total, 265/590 patients (45%) had a LLD greater than 3 mm, 131/590 (22%) had an LLD greater than 5 mm, and 24/590 (4%) had a LLD greater than 10 mm. A LLD beyond ±3 mm significantly worsened all functional scores compared to an LLD below this threshold (PMA: 12.2 ± 3.2 vs. 12.9 ± 3.6 (p = 0.020); HHS: 62.7 ± 20.3 vs. 66.5 ± 19.3 (p = 0.027); FJS: 61.5 ± 28.8 vs. 72.5 ± 25.6 (p < 0.001); and the Oxford-12 score: 29.2 ± 9.7 vs. 26 ± 9.4 (p < 0.001)). However, no significant difference was observed for the autonomy (Parker score 4.7 ± 2.5 versus 4.8 ± 2.7 (p = 0.58)). Female gender (+0.43 mm ± 4.71 (p < 0.001)) and cementing of the femoral implant (+0.42 mm ± 4.57 (p = 0.014)) were associated to lengthening. Cementless stems (-0.41 mm ± 5.29 (p = 0.014)), general anesthesia without curare (-1.8 mm ± 5.96 (p = 0.007)), and the Röttinger and Watson-Jones approaches (-1.34 mm ± 4.57 (p = 0.04)) were associated to shortening. There was no difference between LLD after intracapsular fracture (-0.06 mm ± 5) and extracapsular fracture (+0.9 mm ± 3 (p = 0.45)).

Discussion: Our results are consistent with the literature data which is sparse on the subject, with 78% of LLD in our series ranging between +5 and -5 mm. Functional consequences were observed as soon as the 3 mm threshold was exceeded but without effect on autonomy. Only 4% of patients had a centimeter inequality.

Level of evidence: IV; prospective study without control group.

Keywords: Femoral neck fracture; Hip arthroplasty; Hip fracture; Intracapsular fracture; LLD tolerance threshold; Leg length discrepancy (LLD); Proximal femoral fracture.