Treatment Of Limb Length Discrepancy Research Articles

Evolution of tactical approaches to eliminating limb length discrepancy

Introduction Limb length discrepancy (LLD) can be debilitating and may cause other medical and social problems. LLD is a serious physical condition and have a significant impact on the patient's quality of life changing the gait, forming pathological adaptive mechanisms and causing long-term musculoskeletal disturbances in children. The objective was to analyze the evolution of tactical approaches to the rehabilitation of patients with lower limb length inequality.Material and methods The original literature search was conducted on key resources including Scientific Electronic Library (www.elibrary.ru) and the National Library of Medicine (www.pubmed.org). Literature searches included both Russian and English studies. The search strategy was comprised of keywords: lower limbs, limb length inequality, approaches and means of limb length correction, osteosynthesis. Clinical guidelines, clinical recommendations, systematic reviews, randomized controlled trials and multicenter cohort studies were selected for analysis.Results and discussion Normal individuals can often experience a difference in the length of the lower limbs from several mm to 1.5 cm and have no effect on the gait, condition of adjacent joints and joints of the opposite limb. Some authors report inequality of 5 mm leading to orthopaedic pathology. A variety of conservative and surgical treatments are offered for limb length equalization. Elimination of LLD is a common and unresolved medical problem. Conservative treatment of LLD can be considered as one of the stages of rehabilitation. Some patients can benefit from conservative treatments. Alternatively, surgical equalization is a treatment option for patients with LLD.Conclusion Surgical methods offered earlier to address LLD had disadvantages, which ultimately minimized their use, and orthopaedic surgeons abandoned some of them due to the high risk of severe complications. The device and the technique developed by Dr. Ilizarov in the 50s of the last century was an epoch-making event in the elimination of LLD and are constantly being improved.

The Relationship Between Height and Income With Potential Application to Treatment of Limb Length Discrepancy.

Purpose When treating limb length discrepancy (LLD), decisions regarding lengthening versus contralateral shortening require careful consideration of deformity and patient factors. Using the National Longitudinal Survey of Youth 1979 (NLSY79) database, and income as a quantitative representation of overall socioeconomic benefit, we sought to determine the height at which incremental gains in height have the greatest value. Methods Using the NLSY79 database, we collected demographic data, height, yearly income from wages, college education (full- or part-time), and receipt of government financial aid. Multiple-linear regression and graphical analysis were performed. Results The study population included 9,652 individuals, 4,775 (49.5%) males and 4,877 (50.5%) females. Mean heights were 70.0±3.0 inches and 64.3±2.6 inches for males and females, respectively. Multiple-linear regression analysis (adjusted-r²=0.33) demonstrated height had a standardized-ß=0.097 (p<0.001), even when accounting for confounding factors. Using graphical analysis, we estimated cut-offs of 74 inches for males and 69 inches for females, beyond which income decreased with incremental height. Conclusions Using income as a quantitative representation of socioeconomic value, our analysis found income increased with incremental height in individuals with predicted heights up to 74 inches for males and 69 inches for females. Shortening procedures might receive more consideration at predicted heights greater than these cut-offs, while lengthening might be more strongly considered at the lower ranges of height. Additionally, our multiple-linear regression analysis confirms the correlation between height and income, when factoring in other predictors of income.

Patients’ quality of life assessment following treatment of leg length discrepancy in a single center in Riyadh

Objectives: Length disparities of children’s limbs might make it difficult for them to engage in social, recreational, and leisure activities. The main goals of surgical treatment of limb length discrepancy (LLD) are to restore limb function and prevent adverse social effects. The aim of this study was to assess the quality of life (QoL) of children who received therapy for limb length discrepancies. Methods: Twenty participants fit the inclusion criteria and completed the validated and translated version of the electronic questionnaire of the brief version of the world health organization questionnaire for QoL assessment the brief version (WHO-QoL-BREF). Answering the questionnaire was administered by an interviewer over the phone. The questionnaire comprised basic patient information and questions regarding the QoL. Results: There were 12 male participants and eight females. The total WHO-QoL BREF score of the participants is 94.15 ± 10.01 (out of 125). The differences between the mean scores of all domains according to participants’ demographic, distortion, and surgical variables were insignificant. Conclusion: Ensuring the QoL and function improvement after treatment of LLD is crucial. More attention must be paid to selecting the appropriate procedure for the suitable patient when treating LLD.

Current trends on limb length discrepancy treatment: results of a survey among 11 dedicated Italian centres.

Limb length discrepancies (LLD) are quite frequent, especially in lower limbs. The evolution of the available devices and the refinement of the techniques for correcting the differences in limb length have progressively improved the approach to these deformities. Nevertheless, several points still remain debated. The aim of the study was to investigate the Italian pediatric orthopedic surgeons' choices in approaching and treating LLD in both lower and upper limbs. A survey on the treatment of limb length discrepancy was sent to a group of 11 Italian orthopedic centers, specialising in limb lengthening and belonging to the Italian Society of Pediatric Orthopedics and Trauma and the Italian Society of External Fixation. Despite improvements in knowledge of bone biology and distractional osteogenesis as well as the increase in available hardware for lengthening, many aspects of LLD correction still remain debated. Both the relative rarity of the conditions which lead to significant shortening and the lack of wide groups of patients analysed at adult age, continue to be the main limitations for every surgeon who deals with LLD. Only by overcoming our own convictions and sharing our experiences in multicentric studies, may we reach our goal of developing a shared treatment protocol.

Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails?

Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.

The efficacy of two-hole tension band plates in the treatment of lower extremity limb length discrepancy.

The main purpose of our study was to investigate the efficacy of dual two-hole tension band plates in the treatment of lower extremity limb length discrepancy (LLD). We retrospectively reviewed patients who underwent epiphysiodesis utilizing dual two-hole tension band plates due to lower extremity LLD between January 2012 and June 2018. The efficacy of epiphysiodesis was defined as the inhibited percentage of the expected growth of the physis between two time intervals and was calculated between 0-6 months and 6-18 months as the primary outcome. The relationship of efficacy of epiphysiodesis with time intervals, bone segments, physeal coverage percentage by the screws, age and interscrew angle and physeal health was also assessed. A total of 11 patients' 17 bone segments (9 femurs and 8 tibias) with a mean age of 8.7 ± 2.3 were included. The mean efficacy of the epiphysiodesis in the first 6 months for femurs was 23 ± 20 % (range, 0-53%) and for tibias was 21 ± 19 % (range, 0-53%); between 6 and 18 months it was 27 ± 19 % (range, 0-56%) for femurs and 15 ± 19 % (range, 0-50%) for tibias. In the first 6 months, physeal coverage percentage by the screws (r = 0.503, P = 0.04) and age (r = -0.534, P = 0.027) had a strong correlation with the epiphysiodesis efficacy. Dual two-hole tension band plating has variable efficacy in the treatment of LLD. Age and physeal coverage percentage by the screws could be related to epiphysiodesis efficacy.

Risk factors for focal osteolysis in a stainless-steel limb-lengthening device

Background: Magnetic, telescoping intramedullary lengthening devices are widely used for treatment of limb length discrepancies. However, a routine radiographic review of a stainless-steel device demonstrated soft tissue and bony changes suggestive of osteolysis. Therefore, we sought to examine all patients implanted with a stainless-steel limb-lengthening nail. We specifically asked: (1) what is the incidence of periosteal reaction osteolysis? (2) Is a new biologic reaction classification system valid and reliable? and (3) Are there predictive factors for the development of osteolysis? We hypothesized that higher patient weight and femoral insertion would be risk factors for lysis, due to increased bending moments on the implants. Materials and Methods: A retrospective review of all patients implanted with a stainless-steel limb-lengthening nail between December 2018 and December 2020 was conducted at a single institution. A total of 57 nails in 44 patients were radiographically examined with an average follow-up of 6.2 months (range: 1–21 months). The incidence of osteolysis was calculated through review of patient radiographs. These were then classified according to a novel system by five fellowship-trained orthopedic surgeons with agreement assessed using an intraclass correlation coefficient (ICC). Logistic regression measured predictive factors for this phenomenon. A separate histologic analysis of two bone/soft-tissue biopsies at the time of routine explantation was conducted by an independent pathologist. Results: The incidence of periosteal reaction and osteolysis was 36.8% and 17.5%, respectively. Nails with progression to osteolysis increased to 34.6% (9/26) when examining nails with at least a 6-month follow-up. ICC testing yielded good inter-rater agreement for the novel classification system (average measure: 0.860, 95% confidence interval 0.828–0.888). Age >16 years (P = 0.024) and body weight >150 pounds (P = 0.038) were predictors of osteolysis. Histologic analysis of the biopsies demonstrated an abundance of particulate debris suggestive of chromium reaction. Conclusions: The modular junction of a stainless-steel lengthening device is susceptible to osteolytic changes, and this appears to be associated with increased age and weight. This phenomenon has an apparent time dependence: osteolysis increases with greater follow-up.

Electromagnetic Rod in Lower Limb Lengthening: A Technical Note for Shaft Osteotomy.

ABSTRACTPurposeLong bone lengthening procedures are paramount in the treatment of limb length discrepancies. We witnessed a revolution in the treatment paradigm of this pathology with the development of expandable intramedullary rods. Endomedular nailing might be technically demanding and some steps are critical for success. The aim of authors is to describe a technical note of the PRECICE system that may ease femoral nailing and fixation: the nail can be advanced through the femur and proximal and distal fixation performed previous to complete femoral osteotomy.Materials and methodsThe authors present a case series of XX patients in which the limb lengthening has been performed with partial osteotomy with Gigli saw, nail advancement, proximal and distal fixation, and osteotomy completion at the end of the procedure.ResultsAfter 18 consecutive limb (femoral) lengthening operations with this technical variation in PRECICE, nail patients presented no significant lower limb length discrepancy. There were no records of rotational deformities, nonunion, or infection. Material failure was not reported.ConclusionThis technical note is another positive variable that can help to ease the procedure, minimise possible complications, and confirm magnetic expandable nails as the gold standard technique in limb lengthening procedures and it might be applied to other nailing systems for limb lengthening procedures.How to cite this articleLopes M, Nunes B, Couto A, et al. Electromagnetic Rod in Lower Limb Lengthening: A Technical Note for Shaft Osteotomy. Strategies Trauma Limb Reconstr 2019;14(3):139–141.

Lower limb lengthening and deformity correction in polyostotic fibrous dysplasia using external fixation and flexible intramedullary nailing

The study describes preliminary experience of the use of external fixators for limb lengthening and deformity correction in combination with flexible intramedullary nailing in management of polyostotic fibrous dysplasia. Patients and methodsThe retrospective study included 8 patients (mean age 11.6 ± 3.38 years; range 7–17 years) with polyostotic fibrous dysplasia operated on using external circular frame and flexible intramedullary nailing. Mean follow-up was 2.6 years. Surgical technique consisted of percutaneous osteotomy of a segment and application of circular external frame. The intramedullary nailing was done using two bent nails. Hydroxyapatite-coated nails were applied in three patients; five patients had titanium nails. Amount of lengthening (cm and %), amount of deformity correction, duration of external fixator use, index of external fixation, “nail/medullary canal at narrowest site” ratio, “nail-medullary canal at osteotomy site” ratio were analyzed. Results and complications were assessed according to Lascombes's classification. ResultsThe mean amount of lengthening was 4.5 cm (or 13.7 ± 6.0% per segment). This gave a mean external fixation index of 32.5 ± 13.97 days/cm. The mean ratio of IM nail diameter/medullary canal diameter at the narrowest site was 0.22 ± 0.07 (range, 0.125–0.3 mm). No migration of IM nails into medullary canal were noticed. But in one case there was external migration of Ti-nail. In a year after frame removal, the results of treatment were classified as grade I in 7 cases and IIb in one case.At the latest follow-up control, mechanical axis deviation was found within normal limits in six patients. Two patients had excessive MAD of 11 and 28 mm. In the first case a partial varus deformity recurrence occurred at middle shaft site where a large dysplastic zone was presented. In the second case, a specific shepherd's crook deformity developed and caused excessive MAD. Mean lower limb length discrepancy varied from 1 to 15 mm. ConclusionThere are advantages of using elastic intramedullary nailing and external fixation in the treatment of limb length discrepancy and deformity of long bones in patients with PFD. This strategy ensures reduced external fixation time and high accuracy of alignment. Intramedullary nails left in situ, especially nails with HA-coating, seem to prevent deformity recurrence and stimulate remodeling in dysplastic fibrous zones.

Sagittal plane deformity after temporary epiphysiodesis of the distal femur for correcting limb length discrepancy

BackgroundOutcome of the temporary epiphysiodesis procedure for limb length discrepancy (LLD) is commonly evaluated in the coronal plane. The purpose of this study was to investigate implant position and complications of the distal femur and patella in the sagittal plane after the temporary epiphysiodesis. MethodsWe retrospectively reviewed 27 patients with LLD who underwent temporary epiphysiodesis of the distal femur using staples (11 patients) or eight-plates (16 patients) between 2007 and 2015. The mean age was 9.7 years (range, 6.3–13.8) at the time of epiphysiodesis. The implants were removed after a mean period of 2.6 years (range, 0.8–4.8) from the epiphysiodesis. Correction amount of LLD was measured on anteroposterior long leg standing radiographs. Implant position, extension deformity of the distal femur (>5° from epiphysiodesis to removal of implant) and patella baja (the epiphyseal line midpoint method < 1.0) were evaluated using lateral knee radiographs. ResultsThe average correction amount of LLD was 17.4 mm (range, 2–34). The average implant position was 43.1% (range, 35–55) from the anterior edge of the distal femoral epiphysis. At removal surgery, 16 patients (59%) had extension deformity of the distal femur and 14 patients (52%) showed patella baja. There were significant correlations between implant position and extension deformity (r = −0.51, p < 0.01) and as well as between correction amount of LLD and patella baja (r = −0.64, p < 0.01). ConclusionAfter temporary epiphysiodesis for the treatment of LLD, extension deformity of the distal femur and patella baja occurred frequently. Anterior placement of the implants is associated with extension deformity of the distal femur. The implant should be placed in the center of distal femoral physis, not the center of femoral shaft. Excessive correction of LLD should be avoided due to a risk of patella baja.

Guided growth with tension band plate or definitive epiphysiodesis for treatment of limb length discrepancy?

BackgroundIt is not exactly known whether guided growth or definitive epiphysiodesis techniques are superior in treating limb length discrepancy (LLD). The purpose of the present study was therefore to find out if definitive epiphysiodesis is associated with more powerful LLD correction than tension band plate epiphysiodesis.MethodsPediatric patients with LLD treated either with tension band plating as a guided growth technique (temporary epiphysiodesis) or a percutaneous drilling technique (definitive epiphysiodesis) around the knee and a minimum follow-up of 12 months were included in this retrospective study. Radiographic measurements were performed by two independent reviewers. The reduction in side difference between preoperative radiographs and last follow-up was calculated and compared between surgical techniques.ResultsThirty-eight patients (mean age 13.6 years) were included, 17 treated with temporary and 21 with definitive epiphysiodesis. Average follow-up was at 578 days. The reduction of the LLD in 12 months was 5.7 mm in patients treated with temporary epiphysiodesis and 8.4 mm with definitive epiphysiodesis, respectively (p = 0.22). In both groups, LLD could be statistically significantly reduced after 12 and 24 months. Definitive epiphysiodesis had a lower revision rate (4.8% vs. 17.6%). Intra- and interobserver reliability of the measurements was excellent.ConclusionsAs in earlier studies supposed, temporary epiphysiodesis with tension band plating seems to correct LLD less powerful compared to definitive percutaneous epiphysiodesis. However, in the present study, the differences of LLD correction were not statistically significant. We do not recommend the use of tension band plates for LLD correction due to inferior correction with higher complication and revision rate.

Treatment of bone tumor using external fixator

External fixation has been widely used for the treatment of limb length discrepancy, deformity correction, and bone defect using distraction osteogenesis. We have been using this technique for the treatment of obstacles due to benign bone tumor and reconstruction after malignant bone tumor resection. In this paper, we introduce the usefulness of external fixation for the treatment of various benign bone tumors and limb salvage surgery for reconstruction after tumor resection using distraction osteogenesis, according to the tumor site. The advantages of external fixation for the treatment of benign bone tumor include a possibility of complex deformity correction without treating the tumor itself and reconstruction of the aggressive benign bone tumor as well as solid fixation with wires, even for weak bone due to benign bone tumors. The advantages of treating malignant bone tumor include regeneration of living bone of sufficient strength and durability, biological affinity, resistance against infection, and lifelong restored function. The disadvantages include delayed union at the docking site and pin-or wire-tract infection, patient's psychological stress, and the procedure is time consuming. We conclude that external fixation is very efficient for the treatment of benign and malignant bone tumors.

Treatment of limb length discrepancy following total hip arthroplasty.

Limb length discrepancy is the leading cause of patient dissatisfaction following total hip arthroplasty and the most common reason for litigation in the field of orthopaedics. This article provides a systematic, stepwise approach for identifying the aetiology of limb length discrepancy following total hip arthroplasty and provides guidance on the treatment of this complication to optimize postoperative clinical and functional outcomes. This review discusses postoperative history taking, clinical examination, radiographic assessment, conservative treatment, and surgical intervention for the management of patients with established limb length discrepancy following total hip arthroplasty. A comprehensive understanding of the multifactorial nature and methods of managing postoperative limb length discrepancy is essential for optimizing patient satisfaction, clinical outcomes and long-term function following total hip arthroplasty.

Custom Knee Device for Knee Contractures After Internal Femoral Lengthening.

The development of knee flexion contractures is among the most common problems and complications associated with lengthening the femur with an internal device or external fixator. Conservative treatment strategies include physical therapy, serial casting, and low-load prolonged stretching with commercially available splinting systems. The authors developed an individually molded, low-cost custom knee device with polyester synthetic conformable casting material to treat knee flexion contractures. The goal of this study was to evaluate the results of treatment with a custom knee device and specialized physical therapy in patients who had knee flexion contracture during femoral lengthening with an intramedullary lengthening femoral nail. This retrospective study included 23 patients (27 limbs) who underwent femoral lengthening with an internal device for the treatment of limb length discrepancy. All patients had a knee flexion contracture raging from 10° to 90° during the lengthening process and were treated with a custom knee device and specialized physical therapy. The average flexion contracture before treatment was 36°. The mean amount of lengthening was 5.4 cm. After an average of 3.8 weeks of use of the custom knee device, only 2 of 27 limbs (7.5%) had not achieved complete resolution of the flexion contracture. The average final extension was 1.4°. Only 7 of 27 limbs (26%) required additional soft tissue release. The custom knee device is an inexpensive and effective method for treating knee flexion contracture after lengthening with an internal device.

Limb Lengthening by Implantable Limb Lengthening Devices

Implantable limb lengthening using noninvasively adjusted telescopic nails dates back to 1983. The newest technology is the Precice (Ellipse Technologies). A retrospective study of the first 65 Precice nails was carried out for the treatment of limb length discrepancy (unilateral) and short stature (bilateral). Successful lengthening was achieved in all patients. There were numerous distraction and hardware complications. Despite these, implantable limb lengthening appears to be the direction for the future of limb lengthening.

Guided growth for the treatment of limb length discrepancy

The purpose of this study was to compare the safety and effectiveness of three mechanical devices (percutaneous transphyseal screws, tension band plates, and staples) for the correction of limb length discrepancies in growing children and adolescents. Thirty-nine consecutive patients treated with epiphysiodesis for limb length discrepancy were retrospectively reviewed. No significant difference was recorded between the three devices in postoperative limb length discrepancy or the rate of correction between the plating and stapling groups and between plating and percutaneous transphyseal screws groups. Epiphysiodesis for length discrepancies can be performed effectively using staples, tension band plates, or percutaneous transphyseal screws.

Surgical epiphysiodesis indications and techniques: update

To present a summary of epiphysiodesis indications and to report most recent advances in the field, along with their clinical relevance. Percutaneous epiphysiodesis using transphyseal screws (PETS) and guided growth using eight plates represent the most recent techniques used for hemiepiphysiodesis. PETS and guided growth have yielded very good results and low rates of complications and are the current standard for the management of angular deformities of the lower extremities in children. Permanent percutaneous epiphysiodesis remains the preferred method for the treatment of limb length discrepancies.

Rigidité du cal osseux lors d’une ostéogenèse en distraction

Summary Introduction The treatment of limb length discrepancies by distraction osteogenesis represents a significant challenge of predicting the load bearing capacity. Today, in vivo stiffness measurements by applying compressive, bending or torsional stress on the callus tissue are quantitative methods. Therefore, it is relevant to know how regenerating bone tissue regains its various stiffness characteristics. Knowledge of the development of each type of stiffness is important in order to prevent an over- or underestimation of the actual load bearing capacity. Hypothesis Various types of stiffness are supposed to evolve similar during consolidation. Subjects and methods In this ex vivo study, an analysis of torsional, compressive and bending stiffness of callus tissue during consolidation was performed on 26 sheep tibiae after distraction osteogenesis. Results This study indicates differences within the quantity of stiffness during consolidation. Discussion Thus, in vivo stiffness measurements have to be interpreted carefully in order to prevent false estimation of the load bearing capacity of new bone.

Stiffness of callus tissue during distraction osteogenesis

The treatment of limb length discrepancies by distraction osteogenesis represents a significant challenge of predicting the load bearing capacity. Today, in vivo stiffness measurements by applying compressive, bending or torsional stress on the callus tissue are quantitative methods. Therefore, it is relevant to know how regenerating bone tissue regains its various stiffness characteristics. Knowledge of the development of each type of stiffness is important in order to prevent an over- or underestimation of the actual load bearing capacity.Various types of stiffness are supposed to evolve similar during consolidation.In this ex vivo study, an analysis of torsional, compressive and bending stiffness of callus tissue during consolidation was performed on 26 sheep tibiae after distraction osteogenesis.This study indicates differences within the quantity of stiffness during consolidation.Thus, in vivo stiffness measurements have to be interpreted carefully in order to prevent false estimation of the load bearing capacity of new bone.

Advances in management of limb length discrepancy and lower limb deformity

Limb length discrepancy and lower extremity angular deformity are among the most common nontraumatic conditions in children for which orthopedic referral is sought. There are a number of developments in the surgical management of these problems which have facilitated and improved the quality of care of affected individuals. In recent years, we have developed an improved understanding of ramifications of limb length discrepancy on gait. New treatment options for both limb length discrepancy and deformity include the method of 'guided growth' using small, extraphyseal plates. External fixator technology continues to improve, allowing correction of limb length discrepancy and angular and rotational deformities simultaneously. The development of these techniques for the treatment of limb length discrepancy and angular deformity has expanded the indications for surgical management and decreased the incidence and severity of potential complications.