The Intraoperative Pelvic Radiograph During Total Hip Arthroplasty: Is It Reliable to Estimate Leg Length?

Background: Symptomatic leg length discrepancies (LLDs) are a significant complication after total hip arthroplasty. Many surgeons incorporate an intraoperative anteroposterior pelvis radiograph, to help prevent LLD; however, obtaining a high-quality radiograph is often difficult. The purpose of this study is to evaluate the accuracy and reliability of estimating LLD using different radiographic reference landmarks on suboptimal anteroposterior pelvis radiographs. Material and methods: We obtained 2 pelvis Sawbones models with attached femurs and created a true shortening of the left femur of the experimental model by 7 mm. We then obtained a series of radiographs manipulating each model in standardized increments for a total of 66 different permutations of suboptimal radiographs. Each radiograph was evaluated for LLD by 2 separate orthopedic surgeons using reference lines bisecting the following anatomic landmarks: ischial tuberosities, acetabular teardrops, obturator foramina, sacroiliac joints, and the femoral heads, to the lesser trochanters. The accuracy and reliability of each line were then analyzed. Results: The obturator foramina line yielded the most reliable LLD estimates with an intraclass correlation coefficient of 0.939. This reference line was also the most accurate, with an average difference of 1.5 mm from the true LLD (P < .001), with 95% confidence to be within 1.8 mm. Conclusion: The obturator foramen reference line on an intraoperative radiograph is an accurate and reliable tool that should be utilized by joint replacement surgeons to estimate LLD even if the radiograph is suboptimal. This estimate is reliably reproduced among multiple observers and puts the estimate within 1.8 mm of a true LLD.