Leg Length Discrepancy

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Leg Length Discrepancy

• Mr Matthew Barry MS FRCS(Orth)
• Consultant Orthopaedic Surgeon

The 2nd Annual BLT Paediatric Orthopaedic
Course 6 October 2009
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Overview

• Aetiology
• Complications
• Clinical assessment
• Management
• Outcomes

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Aetiology

• Congenital
• Acquired

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Congenital

• Long bone deficiency
• Fibula
• Femur
• Tibia
• Hemiatrophy
• Silver-Russell
• Hemihypertropy
• Haemangioma
• Lipomatosis
• NF
• Beckwith-Wiedemann
• McCune-Albright

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Fibula Hemimelia

• Most common congenital long bone deficiency
• Incidence 150,000
• Spectrum of severity
• May involve the whole leg
• small fibula absent fibula 3 ray foot

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Fibula Hemimelia

• Classification
• Coventry (1952)
• I partial fibula
• II absent fibula
• III bilateral or femoral involvement or other
  congenital abnormalities
• Achterman Kalamchi (1979)
• IA fibula present
• IB fibula absent 30-50
• II no fibula
• Stanitski (2003)
• fibula morphology I II III
• Distal tibia epiphysis shape H V S
• ? Tarsal coalition c
• Number of rays in foot 1-5

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Acquired

• Trauma
• Overgrowth
• Malunion
• Bone loss
• AVN
• Physeal injury
• Olliers
• Polio
• CP

Apparent LLD hip spine
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Complications

• Does it matter?
• Are there long term adverse effects ?

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• Relationship of limb length inequality with
  radiographic knee and hip osteoarthritis.
• Osteoarthritis Cartilage 2007 15 824-9
• -- Increased risk of knee OA (not hip) with gt2cm
  LLD
• The effect on low back pain of shortening
  osteotomy for leg length inequality.
• Int Ortho. 1992 16 388-91
• -- Reduced LBP symptoms after length equalisation
  (3cm)
• Changes in pain and disability secondary to shoe
  lift intervention in subjects with limb length
  inequality and chronic low back pain a
  preliminary report.
• J Orthop Sports Phys Ther. 2007 37 380-8
• -- Wearing a shoe raise (2cm) reduced LBP
  symptoms

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• Leg-length inequality in people of working age.
  The association between mild inequality and
  low-back pain is questionable.
• Spine 1991 16 429-31.
• Mild LLD (lt2cm) no association with LBP
• Preoperative leg-length inequality and hip
  osteoarthrosis a radiographic study of 100
  consecutive arthroplasty patients.
• Skel Radiol. 2005 34 136-9
• OA more likely on the side of the LONGER leg

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• Leg length inequality. A prospective study of
  young men during their military service. Upsala J
  Med Sci. 1988 93 245-53
• 600 recruits
• lt0.5cm 64
• 0.5-1.5 cm 32
• gt1.5 cm 4
• No correlation between LLD and LBP
• Does unequal leg length cause back pain? A
  case-control study.Lancet. 1984 2 256-8
• No association found
• Short-leg syndrome.BMJ 1971 1 245
• gt1/2 inch shortening required a shoe raise

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• What is the risk of cancer in a child with
  hemihypertrophy?
• Arch Dis Childhood. 2005 90 1312-3
• 5
• Abdominal USS every 3 months until aged 6

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Clinical assessment

• History
• Examination
• Investigations

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Clinical assessment

• History
• Congenital or acquired ?
• Trauma / Infection ?
• Progressive / static ?
• ?syndrome

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Clinical assessment

• Examination
• Gait
• Lower Limb
• Determine which segment is shortened
• Is it too long or too short ?
• Foot
• Exclude fixed deformities knee and foot
• ? Wasting
• Spine
• ?scoliosis fixed or mobile
• Upper limb
• Face

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Clinical assessment

• Examination
• Standing on blocks
• Check that knees fully extended
• ASIS level
• Ask the patient
• Check spine
• Supine
• Real and apparent leg lengths
• Hips / knees / ankles
• Galeazzi (Allis) test

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Clinical assessment

• Investigations
• Standing radiographs
• Block up the shorter leg
• Standardised position patella forwards
• Calibration ball
• CT scannogram

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Radiographs

• Teleorentgenogram
• Single cassette
• Single exposure
• Problem magnification errors
• Orthoroentgenogram
• Single cassette
• 3 exposures centered at hip knee and ankle
• Problem only see the joints
• Scanogram
• 2 or 3 cassettes
• Cassette moved between exposure
• Images stitched togethor
• Problem must keep still

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Management

• Depends on
• the projected LLD at skeletal maturity
• Final height
• Age

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How do I know what the final LLD will be?

• 4 methods
• Arithmetic (Menelaus)
• Growth remaining (Green Anderson)
• Straight line graph (Moseley)
• Limb Multiplier (Paley)

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Chronological vs skeletal age

• Skeletal age
• Use the Greulich and Pyle atlas
• Left hand carpus
• Recommended for Moseley Green / Anderson
  methods
• I use chronological age
• Cundy et al JPO 1988 8 513-515
• Little et al JPO 1996 16 173-179

To comply with the accepted standard, skeletal
age should be used for patients who are 10 years
or older. However, in most cases, we prefer to
use the chronological age.
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Pattern of altered limb growth

• 803 children
• Variety of aetiologies
• PFFD
• Polio
• Traumatic growth arrest
• Olliers
• Perthes
• femur
• CP
• NF
• JRA
• Hemiatrophy / hypertrophy

Shapiro JBJS 1982 64A 639-651
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Type 3 34
Type 4 3
Type 5 8
Type 2 14
Type 1 41
Shapiro JBJS 1982 64A 639-651
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Type 5 11
? 31
Type 4 3
Type 3 22
Type 1 33
n36 Boys 13 Girls 23
Type 2 0
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Arithmetic method of Menelaus

• Main use is to time growth arrest
• Makes assumptions
• Boys stop growing at 16
• Girls stop at 14
• Distal femur 10mm / year
• Proximal tibia 6mm / year

Eastwood Cole JBJS 1995 77B 743-747
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Growth Remaining

• Determine the length of the long leg at maturity
• Calculate the future growth of the long leg
• Calculate the inhibition of the short leg
• Calculate the future increase in the discrepancy

Anderson et al JBJS 1963 45A 1-14
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Moseley straight line method

• Graphical representation of the Green Anderson
  method

Moseley JBJS 1977 59A 174-179
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Lower Limb Multiplier

• Uses the Anderson data
• Shapiro type 1 pattern
• Boys and girls use different multiplier
• Chronological age
• Clinical leg lengths (?)

Paley et al JBJS 2000 82A 1432-1446
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Management

• Projected LLD at skeletal maturity
• lt 2cm nothing / shoe raise
• 2-4 cm contralateral growth arrest
• gt4 cm limb lengthen
• gt15 cm ?amputation
• ? limb shorten

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Management
Shoe raise

• Advantage
• Cheap
• Safe

• Disadvantage
• No good for bare feet
• Cosmetic

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Management

• Contra-lateral growth arrest
• Timing
• Method
• Femur, tibia or both ?

• Advantage
• Day case
• Minimal scars

• Disadvantage
• Will affect final height

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Timing of growth arrest

• Menelaus
• Moseley method
• Limb multiplier

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Menelaus

• Boys stop growing at 16
• Girls stop at 14
• Distal femur 10mm / year
• Proximal tibia 6mm / year

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Growth arrest

• Method
• Phemister technique
• Percutaneous drilling
• Distal femur
• Proximal tibia (NB fibula)
• II control
• Multiple drill passages from each side

McCarthy JPO 2003 23 52-54
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Limb lengthening

• Internal
• ISKD
• Albizzia
• Fitbone
• External
• Circular frame
• Monolateral
• Combined
• Lengthening over a nail
• Lengthening over a plate

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Limb lengthening

• Low energy osteotomy
• Osteotome
• Gigli saw
• Di Bastiani technique
• Callus distraction
• Start 1 week postop
• 1mm/day
• Maximum length increase 25

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Amputation

• Consider in
• large discrepancies gt15cm
• Unstable joints
• Severe fixed deformities
• Amputation in children
• Aged 1 2 years
• Through joint
• Preserve distal physis ? maximise length
• Avoid bone spike

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Outcomes

• Cosmetic limb lengthening JBJS 2005 87B
  1402-1405
• n54
• Mean 7cm length gain (5-11)
• Frame time 9 months (7-18)
• 35 required bilat TA lengthening
• 11 additional surgery
• 24 additional complications
• Cost 12000 ( 3000 for TAL!)

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Outcomes

• Fibular Hemimelia Comparison of Outcome
  Measurements After Amputation and
  LengtheningJBJS 2000 82A 1732-1735

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Summary

• Cause of LLD
• Congenital or acquired
• 5 patterns of altered limb growth described
• Predicting the LLD at skeletal maturity
• Menelaus
• Moseley straight line method
• Paley Multiplier
• Management
• Shoe raise
• Timed growth arrest
• Lengthen
• Amputate

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