Abstract
Any lower limb discrepancy may be equalised by conservative means (insoles, prosthesis and orthosis). However, their long-term acceptance is low in regard to function, costs, expenditure and appearance. Timely epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile. However, many patients present late or with multi-planar deformities, which warrant more sophisticated operative approaches. The history of surgical bone lengthening comprises 100 exciting years of struggling, development and ongoing learning. The initial strategy of acute or rapid incremental distraction had lasted almost half a century until Ilizarov recognised the benefits of biological periosteum-preserving osteotomies and incremental lengthening at slow rates (1mm/day) at a 4×0.25-mm daily rhythm, well appreciated as callotasis. In parallel, ring and wire constructs made complex three-dimensional axial, translational and rotational bone moulding possible. Taylor Spatial Frames-built on hexapod strut-linked platform technology as known from flight simulators-took limb correction to a more reliable, more precise and aesthetical level, all the more that the whole process became web-based. It represents state-of-the-art methodology and technology for complex, multi-plane deformities. Due to the significant risk of secondary malalignment, indications for lengthening by unilateral fixation have shrunken to moderate amounts of length disparity and uni- to bi-planar deformities in patients with still open physes. Mechanical or motorised, minimally invasively placed nails prevent muscle fixation and, therefore, ease rehabilitation, increase patient comfort and potentially shorten the overall time of sick leave and refrain from sports activities. Hence, they offer a valuable alternative for low-grade complexity situations. It remains to be proved if the significantly higher implant costs are compensated by lower treatment costs. Overall, limb lengthening, particularly in combination with multi-planar deformity correction, can still be an arduous endeavour. In any case, wise judgement of the patient's deformity, medical and biological situation, psychosocial environment, selection of the appropriate method and hardware, as well as meticulous operating technique by an experienced surgeon are the cornerstones of successful outcomes.
Highlights
Leg length discrepancies are frequent: about one-third of the population shows 0.5–1.5-cm disparities, 5 % more than 1.5 cm and about 1/1,000 have been prescribed a shoe lift [1,2,3].Despite a lack of biomechanical data supporting a seemingly fundamental human anatomic principle, it is persistent orthopaedic common sense that the pelvis needs to be horizontal and the lumbar spine symmetrically loaded in a bipedal standing position and in the stance phase during gait
Epiphysiodesis is the best option in uniplanar deformities with adequate remaining growth and for patients whose predicted final body height is above the 50th percentile
Concurring implants and techniques for mechanical bone guidance such as Taylor Spatial Frames (TSFs), traditional Ilizarov ring and wire constructs, various methods for unilateral external fixation and intramedullary mechanical or motor-driven nails offer space for individual application given by the skills and preferences of the surgeon, the affordability, the patient’s needs and wishes, and the medical problem defined as a mixture of bony deformity and the condition of the joint, muscle and soft tissue compound adjoining the segment to be corrected
Summary
Leg length discrepancies are frequent: about one-third of the population shows 0.5–1.5-cm disparities, 5 % more than 1.5 cm and about 1/1,000 have been prescribed a shoe lift [1,2,3]. Concurring implants and techniques for mechanical bone guidance such as Taylor Spatial Frames (TSFs), traditional Ilizarov ring and wire constructs, various methods for unilateral external fixation and intramedullary mechanical or motor-driven nails offer space for individual application given by the skills and preferences of the surgeon, the affordability, the patient’s needs and wishes, and the medical problem defined as a mixture of bony deformity and the condition of the joint, muscle and soft tissue compound adjoining the segment to be corrected We deemed it worthwhile to shine through the current body of knowledge.
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