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Three Part Question

Does [correcting leg length discrepancy] improve [functional outcomes] of [adults following hip fracture surgery]?

Clinical Scenario

Ward 32 is an acute rehabilitation ward. Many patients that come across for further rehabilitation have had hip surgery following a fractured neck of femur. It had been observed that several patients had a leg length discrepancy following their surgery and so an audit on the prevalence of post-surgical leg length discrepancy demonstrated that 50% of patients transferred to ward 32 post hip fracture had a LLD and these patients were routinely referred to orthotics for correction. On discussion with both Podiatrist and Orthotist it was established that common practice would be to correct half the LLD. The physiotherapists delivering rehabilitation on the ward felt that clinically patient’s functional improvements were greater following LLD correction.

Search Strategy

AMED 1985-present, MEDLINE 1966-present and CINAHL 1982-present databases were searched.
Search terms in Title & Abstract
AMED, MEDLINE and CINAHL databases:
(Adults) AND (Hip Fracture)OR(fractured neck of femur)OR(dynamic hip screw)OR(hemi-arthroplasty)OR (proximal femoral nail)OR(IM nail)AND(leg length discrepancy)OR(leg length inequality)OR(leg length difference) AND (Shoe raise)OR(Heel Raise)OR(heel wedge)OR(Shoe lift) AND (Walking)OR(Gait)OR (balance)OR(independence)OR(falls risk)OR(pain)

Search Outcome

The numbers of articles felt to be relevant were as follows. AMED; 1 article from 181 results. MEDLINE; 1 article from 158 results (1 duplicate from AMED). CINAHL; 0 articles from 200 results

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Schuit. D, Adrian. M and Pidcoe. P. 1989 USA	N = 18 Volunteers 20-63 years old with structural LLD	Before and after experimental: Participants were their own control	1. Pelvic levelness	Prior to HL fitting MLF (supination) was greater (p < .05) in the SL foot that in the LL foot	Small sample size. Unable to compare between subjects. Force plate measurement – not individual joint force data therefore less comparable to previous research Poor reporting of data – no table with significance values clear for reader to view.

Comment(s)

No papers were found that answered the three part question in full. One paper was found that was considered to have a degree of relevance to the question. This study looked at the effect of heel lifts on ground reaction force as a component of gait. The study does suggest that the addition of a heel lift increases the ground reaction forces which may cause increased joint stress within the lower extremities. However, this study did not consider the functional benefits of the effect of a heel lift to correct leg length discrepancy.

Clinical Bottom Line

There is no current evidence available to suggest that correction of leg length discrepancy with a heel lift in adults post hip fracture leads to improved functional outcomes.

References

1. Schuit. D, Adrian. M and Pidcoe. P. Effect of Heel Lifts and Ground Reaction Force Patterns in Subjects with Structural Leg-Length Discrepancies 69(8): 662-670