Height Reduction Surgery (Bone-shortening Surgery)

What is Limb Length Discrepancy?

Limb Length Discrepancy (LLD), where one limb is a different length than its opposing limb, can be due to many causes. These are divided into three major groups:

. Congenital (from birth)

. Developmental (from a childhood disease or injury that slows or damages the growth plates),

. Posttraumatic (from a fracture that leads to shortening of the bone ends).

About Iranian Surgery

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For more information about the cost of Height Reduction Surgery (Bone-shortening Surgery) in Iran and to schedule an appointment in advance, you can contact Iranian Surgery consultants via WhatsApp number +98 901 929 0946. This service is completely free.

Before Height Reduction Surgery (Bone-shortening Surgery)

Cause of Limb Length Discrepancy (LLD)

. Previous Injury to a Bone in the Leg

A broken leg bone can lead to a limb length discrepancy if it heals in a shortened position. This is more likely to happen if the bone was broken into many pieces. It is also more likely to happen if the skin and muscle tissue around the bone were severely injured and exposed, as occurs in an open fracture.

In a child, a broken bone sometimes grows faster for several years after healing, causing it to become longer than the bone on the opposite side. This type of overgrowth occurs most often in young children with femur (thighbone) fractures.

Alternatively, a break in a child’s bone through the growth plate near the end of the bone may cause slower growth, resulting in a shorter leg.

. Bone Infection

Bone infections that occur in growing children may cause a significant limb length discrepancy. This is especially true if the infection happens in infancy.

. Bone Diseases (Dysplasias)

Certain bone diseases may cause limb length discrepancy, including:

. Neurofibromatosis

. Multiple hereditary exostoses

. Ollier disease

Other Causes

Other causes of limb length discrepancy include:

. Neurologic conditions

. Conditions that cause inflammation of the joints during growth, such as juvenile arthritis.

In some cases, the cause of limb length discrepancy is “idiopathic,” or unknown. This is particularly true in cases involving underdevelopment of the inner or outer side of the leg, or partial overgrowth of one side of the body.

These conditions are usually present at birth, but the limb length difference may be too small to be detected early on. As the child grows, however, the discrepancy increases and becomes more noticeable. In underdevelopment, one of the two bones between the knee and the ankle is abnormally short. The child may also have related foot or knee problems.

Hemihypertrophy (one side too big) and hemiatrophy (one side too small) are rare conditions that cause limb length discrepancy. In patients with these conditions, the arm and leg on one side of the body are either longer or shorter than the arm and leg on the opposite side. There may also be a difference between the two sides of the face. In some cases, the exact cause of these conditions cannot be determined.

Symptoms of Limb Length Discrepancy (LLD)

The effects of limb length discrepancy vary from patient to patient, depending on the cause and size of the difference.

Patients who have differences of 3-1/2 to 4 percent of total leg length (about 4 cm or 1-2/3 inches in an average adult) may limp or have other difficulties when walking. Because these differences require the patient to exert more effort to walk, he or she may tire easily.

Some studies show that patients with limb length discrepancies are more likely to experience low back pain and are more susceptible to injury. Other studies do not support this finding, however.

Diagnosis

How is leg length discrepancy diagnosed?

. Doctor Examination

Parents are usually the first to detect a leg length discrepancy when they notice a problem with the way their child walks. Discrepancies are also sometimes detected when a child undergoes a screening at school for curvature of the spine (scoliosis). It is important to note, however, that leg length discrepancy does not cause scoliosis.

Your doctor will conduct a thorough physical examination and use tests to confirm or diagnosis a discrepancy in length.

. Physical Examination

During the exam, your doctor will ask about your child’s general health, medical history, and symptoms. He or she will then perform a careful examination, observing how your child sits, stands, and moves.

. Gait analysis. During the examination, your doctor will closely observe your child’s gait (the way he or she walks). Young children may compensate for a limb length discrepancy by flexing their knee or walking on their toes.

. Measuring the discrepancy. In most cases, the doctor will measure the discrepancy when your child is standing barefoot. He or she will place a series of wooden blocks under the short leg until the hips are level, then measure the blocks to determine the discrepancy.

. Imaging Studies

. X-rays. An x-ray provides images of dense structures, such as bone. If your doctor needs a more precise measurement of the discrepancy, he or she may order x-rays of your child’s legs.

. Scanograms. This is a special type of x-ray that uses a series of three images and a ruler to measure the length of the bones in the legs. Your doctor may order a scanogram instead of, or in addition to, a traditional x-ray.

. Computerized tomography (CT) scans. These studies can provide a more detailed image of the bone and soft tissue in the legs. In some cases, your doctor will use a CT scan to measure the limb length discrepancy.

If your child is still growing, your doctor may repeat the physical examination and imaging studies every six months to a year to see if the discrepancy has increased or remained the same.

Because an x-ray measurement cannot be compared with a CT scan measurement, your doctor will follow your child with the same type of imaging study over time.

Who’s a good candidate for Height Reduction Surgery (Bone-shortening Surgery)?

. Candidates for an epiphysiodesis

An epiphysiodesis is more frequently used for children and teenagers who are still growing.

This surgery must be timed precisely so that the bone that’s not impaired by surgery will be able to catch up to (but not surpass) the length of the other bone.

. Candidates for bone-shortening surgery

A bone-shortening surgery is often best for young adults and adults who are finished growing. Most people are at their final height by age 18 to 20.

It’s only when you’ve reached this full height that a doctor has the best understanding of how much bone should be removed to even out any limb length differences.

Side effects and Complications

What are the side effects or risks of bone-shortening surgery?

Bone-shortening surgeries aren’t without risk. With an epiphysiodesis, potential side effects or complications include:

. Infection

. Bleeding

. Deformity of bone growth

. Continued growth of bones

. Over- or under-correction that doesn’t eliminate the difference

Potential risks or side effects of bone-shortening surgery include:

. Bones that heal out of alignment

. Infection

. Bleeding

. Over- or under-correction

. Nonunion, or bones that fail to properly join during healing

. Pain

. Loss of function

During Height Reduction Surgery (Bone-shortening Surgery)

What procedures are involved?

Two types of surgery may be used to reduce a leg bone’s length. Which your surgeon may recommend depends on your age and the outcome you’re looking to reach.

. Epiphysiodesis

Epiphysiodesis is essentially surgical destruction of the growth plates at the end of bones. With age, these growth plates produce bone material that hardens.

During this procedure, a surgeon scrapes or drills holes in the growth plates to prevent them from expanding or to slow them down. The surgeon may also put a metal plate around the growth plates to prevent additional bone development.

. Limb-shortening surgery

The second procedure is called a limb-shortening surgery. As the name suggests, this surgery actually shortens the length of a bone, possibly affecting your overall height.

To do this, a surgeon removes a portion of the femur (thighbone) or tibia (shinbone). Then, they use metal plates, screws, or rods to hold the remaining pieces of bone together until they heal.

Healing may take several weeks and require you to have very limited movement. In fact, you may be in a full-length leg cast for weeks until your doctor is satisfied that the bone has healed properly.

The maximum length a surgeon can remove from the femur is about 3 inches (7.5 centimeters); from the tibia, it’s about 2 inches (5 centimeters). How much your surgeon removes will depend on the discrepancy they’re trying to correct.

After Height Reduction Surgery (Bone-shortening Surgery)

Recovery and Aftercare

After an epiphysiodesis procedure, hospitalization is required for about a week. Occasionally, a cast is placed on the operated leg for some three to four weeks. Healing usually requires from eight to 12 weeks, at which time full activities can be resumed.

In the case of leg shortening surgery, two to three weeks of hospitalization is common. Occasionally, a cast is placed on the leg for three to four weeks. Muscle weakness is common, and muscle-strengthening therapy is started as soon as tolerated after surgery. Crutches are required for six to eight weeks. Some patients may require from six to 12 months to regain normal knee control and function. The intramedullary rod is usually removed after a year.

During the recovery period, physical therapy plays a very important role in keeping the patient’s joints flexible and in maintaining muscle strength. Patients are advised to eat a nutritious diet and to take calcium supplements. To speed up the bone healing process, gradual weight-bearing is encouraged. Patients are usually provided with an external system that stimulates bone growth at the site, either an ultrasound device or one that creates a painless electromagnetic field.

Results

Epiphysiodesis usually has good outcomes when performed at the correct time in the growth period, though it may result in an undesirable short stature.

Bone shortening may achieve better correction than epiphysiodesis, but requires a much longer convalescence.