Original Article|Articles in Press

A large preoperative pelvic oblique angle affects perception of leg length discrepancy after total hip arthroplasty

Published:February 24, 2023DOI:



      In some cases, patients feel a perceived leg length discrepancy (P-LLD) despite no radiographic leg length discrepancy (R-LLD) after total hip arthroplasty (THA). We aimed to investigate the rate of postoperative P-LLD and the factors that cause postoperative P-LLD.


      A retrospective study was conducted on 100 patients with R-LLD ≤5 mm after THA. Patients were classified into two groups based on P-LLD post-THA: group P (with P-LLD) and group E (without P-LLD). Relevant data on the general characteristics and radiological findings between the two groups were compared.


      We observed that 25 & 75% of patients belonged to group P and group E, respectively, with no significant difference in patient background. Postoperative Japanese Orthopedic Association (JOA) classification of pain and activities of daily living scores were significantly lower in group P than in group E (37.2 ± 3.9 vs. 39.1 ± 2.2, respectively; P = 0.013, and 16.2 ± 4.2 vs. 18.2 ± 2.2, respectively; P = 0.011). The preoperative pelvic oblique angle (POA) was significantly larger in group P than in group E (3.3 ± 2.3° vs. −0.2 ± 2.1°; respectively; P < 0.01). The pelvis tilted toward the surgical side was significantly higher in group P than in group E(88% vs 57%; respectively; P = 0.013). The preoperative C7 coronal vertical axis (C7 CVA) was significantly larger in group P than in group E (6.7 ± 14.7 mm vs. −0.2 ± 10.3 mm; respectively; P = 0.028). Multivariate logistic analysis revealed that preoperative POA (OR, 3.71; 95% CI: 1.86–8.12; P < 0.01) and the pelvis tilted toward the surgical side (OR, 4.14; 95% CI: 2.07–9.71; P = 0.022) were independent risk factors for P-LLD after THA.


      Even though there was no postoperative R-LLD, 25% of patients had P-LLD. A large preoperative POA and the pelvis tilted toward the surgical side were independent risk factors for P-LLD after THA.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Orthopaedic Science
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ethgen O.
        • Bruyere O.
        • Richy F.
        • Dardennes C.
        • Reginster J.Y.
        Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
        J Bone Joint Surg Am. 2004 May; 86: 963-974
        • Nakashima Y.
        • Sato T.
        • Yamamoto T.
        • Motomura G.
        • Ohishi M.
        • Hamai S.
        • et al.
        Results at a minimum of 10 years of follow-up for AMS and PerFix HA-coated cementless total hip arthroplasty: impact of cross-linked polyethylene on implant longevity.
        J Orthop Sci. 2013 Nov; 18: 962-968
        • Hamai S.
        • Nakashima Y.
        • Mashima N.
        • Yamamoto T.
        • Kamada T.
        • Motomura G.
        • et al.
        Comparison of 10-year clinical wear of annealed and remelted highly cross- linked polyethylene: a propensity-matched cohort study.
        J Mech Behav Biomed Mater. 2016 Jun; 59: 99-107
        • Desai A.S.
        • Dramis A.
        • Board T.N.
        Leg length discrepancy after total hip arthroplasty: a review of literature.
        Curr Rev Musculoskelet Med. 2013 Dec; 6: 336-341
        • Bokshan S.L.
        • Ruttiman R.J.
        • DePasse J.M.
        • Eltorai A.E.M.
        • Rubin L.E.
        • Palumbo M.A.
        • et al.
        Reported litigation associated with primary hip and knee arthroplasty.
        J Arthroplasty. 2017 Dec; 32 (e1): 3573-3577
        • Wylde V.
        • Whitehouse S.L.
        • Taylor A.H.
        • Pattison G.T.
        • Bannister G.C.
        • Blom A.W.
        Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement.
        Int Orthop. 2009 Aug; 33: 905-909
        • Edeen J.
        • Sharkey P.F.
        • Alexander A.H.
        Clinical significance of leg-length inequality after total hip arthroplasty.
        Am J Orthoped. 1995 Apr; 24: 347-351
        • Sykes A.
        • Hill J.
        • Orr J.
        • Humphreys P.
        • Rooney A.
        • Morrow E.
        • et al.
        Patients' perception of leg length discrepancy post total hip arthroplasty.
        Hip Int. 2015 Sep-Oct; 25: 452-456
        • Koga D.
        • Jinno T.
        • Okawa A.
        • Morita S.
        • Shinomiya K.
        The effect of preoperative lateral flexibility of the lumbar spine on perceived leg length discrepancy after total hip arthroplasty.
        J Med Dent Sci. 2009 Mar; 56: 69-77
        • Tekemoto G.
        • Osawa Y.
        • Seki T.
        • Takegami Y.
        • Ochiai S.
        • Kato D.
        • et al.
        Factors influencing inconsistent leg length discrepancy in dysplastic hip osteoarthritis: a retrospective study.
        BMC Muscoskel Disord. 2022 Apr 23; 23: 381
        • Woolson S.T.
        • Harris W.H.
        A method of intraoperative limb length measurement in total hip arthroplasty.
        Clin Orthop Relat Res. 1985 Apr; 194: 207-210
        • Kuribayashi M.
        • Takahashi K.
        • Fujioka M.
        • Ueshima K.
        • Inoue S.
        • Kubo T.
        Reliability and validity of the Japanese Orthopaedic Association hip score.
        J Orthop Sci. 2010 Jul; 15: 452-458
        • Seki T.
        • Hasegawa Y.
        • Ikeuchi K.
        • Ishiguro N.
        • Hiejima Y.
        Reliability and validity of the Japanese orthopaedic association hip disease evaluation Questionnaire (JHEQ) for patients with hip disease.
        J Orthop Sci. 2013 Sep; 18: 782-787
        • Crowe J.F.
        • Mani V.J.
        • Ranawat C.S.
        Total hip replacement in congenital dislocation and dysplasia of the hip.
        J Bone Joint Surg Am. 1979 Jan; 61: 15-23
        • Kabata T.
        • Kajino Y.
        • Inoue D.
        • Ohmori T.
        • Yoshitani J.
        • Ueno T.
        • et al.
        Safety range for acute limb lengthening in primary total hip arthroplasty.
        Int Orthop. 2019 Sep; 43: 2047-2056
        • Lazennec J.Y.
        • Folinais D.
        • Florequin C.
        • Pour A.E.
        Does patients' perception of leg length after total hip arthroplasty correlate with anatomical leg length?.
        J Arthroplasty. 2018 May; 33: 1562-1566
        • Nakahara I.
        • Takao M.
        • Sakai T.
        • Nishii T.
        • Yoshikawa H.
        • Sugano N.
        Gender differences in 3D morphology and bony impingement of human hips.
        J Orthop Res. 2011 Mar; 29: 333-339
        • Uemura K.
        • Takao M.
        • Otake Y.
        • Koyama K.
        • Yokota F.
        • Hamada H.
        • et al.
        Can anatomic measurements of stem anteversion angle be considered as the functional anteversion angle?.
        J Arthroplasty. 2018 Feb; 33: 595-600
        • Nakashima H.
        • Kawakami N.
        • Ohara T.
        • Saito T.
        • Tauchi R.
        • Imagama S.
        A new global spinal balance classification based on individual pelvic anatomical measurements in patients with adult spinal deformity.
        Spine. 2021 Feb 15; 46: 223-231
        • Iwakiri K.
        • Ohta Y.
        • Fujii T.
        • Minoda Y.
        • Kobayashi A.
        • Nakamura H.
        Changes in patient-perceived leg length discrepancy following total hip arthroplasty.
        Eur J Orthop Surg Traumatol. 2021 Oct; 31: 1355-1361
        • Fujita K.
        • Kabata T.
        • Kajino Y.
        • Tsuchiya H.
        Optimizing leg length correction in total hip arthroplasty.
        Int Orthop. 2020 Mar; 44: 437-443
        • Iversen M.D.
        • Chudasama N.
        • Losina E.
        • Katz J.N.
        Influence of self-reported limb length discrepancy on function and satisfaction 6 years after total hip replacement.
        J Geriatr Phys Ther. 2011 Jul-Sep; 34: 148-152
        • Adams C.T.
        • O'Leary R.E.
        • Gheewala R.A.
        • Roberts J.T.
        Evolving patient perception of limb length discrepancy following total hip arthroplasty.
        J Arthroplasty. 2021 Jul; 36: S374-S379
        • Zuckerman S.L.
        • Lai S.C.
        • Shen Y.
        • Cerpa M.
        • Lee J.N.
        • Kerolus M.G.
        • et al.
        Understanding the role of pelvic obliquity and leg length discrepancy in adult spinal deformity patients with coronal malalignment: unlocking the black box.
        J Neurosurg Spine. 2022 Jan 14; : 1-9
        • Buyukaslan A.
        • Abul K.
        • Berk H.
        • Yilmaz H.
        Correction to: leg length discrepancy and adolescent idiopathic scoliosis: clinical and radiological characteristics.
        Spine Deform. 2022 Mar; 10: 315-316
        • Pheasant M.S.
        • Coulter J.L.
        • Wallace C.
        • Kropp Lopez A.K.
        • DelSole E.M.
        • Mercuri J.J.
        Lumbar spine fusion and symptoms of leg length discrepancy after hip arthroplasty.
        J Arthroplasty. 2021 Sep; 36 (e1): 3241-3247
        • Sariali E.
        • Mueller M.
        • Klouche S.
        A higher reliability with a computed tomography scan-based three dimensional technique than with a two dimensional measurement for lower limb discrepancy in total hip arthroplasty planning.
        Int Orthop. 2021 Dec; 45: 3129-3137
        • Zadoń H.
        • Nowakowska-Lipiec K.
        • Michnik R.
        A sitting or standing position - which one exerts more loads on the musculoskeletal system of the lumbar spine? Comparative tests based on the methods of mathematical modelling.
        Acta Bioeng Biomech. 2021; 23: 113-120
        • Philippot R.
        • Wegrzyn J.
        • Farizon F.
        • Fessy M.H.
        Pelvic balance in sagittal and Lewinnek reference planes in the standing, supine and sitting positions.
        Orthop Traumatol Surg Res. 2009 Feb; 95: 70-76