Surgical treatments vary in complexity. Sometimes the goal of surgery is to stop the growth of the longer limb. Other times, surgeons work to lengthen the shorter limb. Orthopedic surgeons may treat children who have limb-length conditions with one or a combination of these surgical techniques. Bone resection. An operation to remove a section of bone, evening out the limbs in teens or adults who are no longer growing. Epiphyseal stapling. An operation to slow the rate of growth of the longer limb by inserting staples into the growth plate, then removing them when the desired result is achieved. Epiphysiodesis. An operation to slow the rate of growth of the longer limb by creating a permanent bony ridge near the growth plate. Limb lengthening. A procedure (also called distraction osteogenesis or the Ilizarov procedure) that involves attaching an internal or external fixator to a limb and gradually pulling apart bone segments to grow new bone between them. There are several ways your doctor can predict the final LLD, and thus the timing of the surgery. The easiest way is the so-called Australian method, popularised by Dr. Malcolm Menelaus, an Australian orthopedic surgeon. According to this method, growth in girls is estimated to stop at age 14, and in boys at age 16 years. The femur grows at the rate of 10 mm. a year, and the upper tibia at the rate of 6 mm. a year. Using simple arithmetic, one can get a fairly good prediction of future growth. This of course, is an average, and the patient may be an average. To cut down the risk of this, the doctor usually measures leg length using special X-ray technique (called a Scanogram) on three occasions over at least one year duration to estimate growth per year. He may also do an X-ray of the left hand to estimate the bone age (which in some cases may differ from chronological age) by comparing it with an atlas of bone age. In most cases, however, the bone age and chronological age are quite close. Another method of predicting final LLD is by using Anderson and Green?s remaining growth charts. This is a very cumbersome method, but was till the 1970?s, the only method of predicting remaining growth. More recently, however, a much more convenient method of predicting LLD was discovered by Dr. Colin Moseley from Montreal. His technique of using straight line graphs to plot growth of leg lengths is now the most widely used method of predicting leg length discrepancy. Whatever method your doctor uses, over a period of one or two years, once he has a good idea of the final LLD, he can then formulate a plan to equalize leg lengths. Epiphyseodesis is usually done in the last 2 to 3 years of growth, giving a maximum correction of about 5 cm. Leg lengthening can be done at any age, and can give corrections of 5 to10 cm., or more.
There are many causes of leg length discrepancy. Structural inequality is due to interference of normal bone growth of the lower extremity, which can occur from trauma or infection in a child. Functional inequality has many causes, including Poliomyelitis or other paralytic deformities can retard bone growth in children. Contracture of the Iliotibial band. Scoliosis or curvature of the spine. Fixed pelvic obliquity. Abduction or flexion contraction of the hip. Flexion contractures or other deformities of the knee. Foot deformities.
Patients with significant lower limb length discrepancies may walk with a limp, have the appearance of a curved spine (non-structural scoliosis), and experience back pain or fatigue. In addition, clothes may not fit right.
A doctor will generally take a detailed medical history of both the patient and family, including asking about recent injuries or illnesses. He or she will carefully examine the patient, observing how he or she moves and stands. If necessary, an orthopedic surgeon will order X-ray, bone age determinations and computed tomography (CT) scans or magnetic resonance imaging (MRI).
Non Surgical Treatment
The object of treatment for leg length discrepancy is to level the pelvis and equalize the length of the two limbs. Inequalities of 2-2.5 centimeters can be handled with the following. Heel lifts/ adjustable heel lifts can be used inside a shoe where shoes have a full heel counter. Heel lifts may be added to the heel on the outside of the shoe along with an internal heel lift. Full platforms along the forefoot and rearfoot area of a shoe can be added. There are many different adjustable heel lifts available on the market. For treatment of a leg length discrepancy, consult your physician. They may refer you to a Physiotherapist or Chiropractor for determination of the type of LLD. A Certified Pedorthist (Canada) will treat a structural leg length discrepancy with a heel lift or in larger discrepancies a footwear modification.
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Epiphysiodesis is a surgical option designed to slow down the growth of the long leg over a period of months to years. It is only used in growing children. The operation involves a general anaesthetic. Small incisions are made around the knee near the growth plates of the thigh bone and the shin bone. The growth plates are prevented from growing by the use of small screws and plates (?8 - plates?). The screws are buried beneath the skin and are not visible. Stitches are buried beneath the skin and do not need to be removed. The child is normally in hospital for 2-3 days. The child can weight bear immediately and return back to normal activity within a few weeks. Long term follow up is required to monitor the effects of the surgery. The timing of the surgery is based on the amount of growth predicted for the child. Therefore, this procedure can under- and over-correct the difference in leg length. Occasionally the screws have to be removed to allow growth to continue. This procedure can be used on one half of the growth plate to correct deformity in a limb e.g. knock-knees or bow legs. This is known as hemiepiphysiodesis.