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).
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About Iranian Surgery
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For more information about the cost of limb length discrepancy treatment 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 Limb Length Discrepancy
. 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:
. Multiple hereditary exostoses
. Ollier disease
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.
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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.
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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.
Risks and Complications
All the risks associated with surgery and the administration of anesthesia exist, including adverse reactions to medications, bleeding and breathing problems.
Specific risks associated with LLD surgery include:
. Osteomyelitis (bone infection)
. Nerve injury that can cause loss of feeling in the operated leg
. Injury to blood vessels
. Poor bone healing (non-union)
. Avascular necrosis (AVN) of the femoral head as a result of vascular damage during surgery
. Chondrolysis (destruction of cartilage) following insertion of rods and pins
. Hardware failure, failure of epiphysiodesis, failure of slip progression
. Unequal limb lengths if one leg fails to heal properly (The physician may need to reverse the direction of the external fixator device to strengthen it, causing a slight discrepancy between the two legs.)
. Joint stiffness (contractures) may occur during lengthening, especially significant lengthening.
. Pin loosening in the anchor sites
Another serious specific risk associated with leg lengthening/shortening surgery is infection of the pins or wires going through the bone and/or resting on the skin that may result in further bone or skin infections (osteomyelitis, cellulitis, staph infections).
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During Limb Length Discrepancy
Your doctor will consider several things when planning your child's treatment, including:
. The size of the discrepancy
. Your child's age
. The cause of the discrepancy, if known
. Nonsurgical Treatment
For patients with minor limb length discrepancies (less than 1 inch) and no deformity, treatment is usually nonsurgical in nature. Because the risks of surgery may outweigh the benefits, surgical treatment to equalize small differences in leg length is not usually recommended.
Nonsurgical treatments may include:
. Observation. If your child has not yet reached skeletal maturity, your doctor may recommend simple observation until growing is complete. During this time, your child will be reevaluated at regular intervals to determine whether the discrepancy is increasing or remaining the same.
. Wearing a shoe lift. A lift fitted to the inside or outside of the shoe can often improve a patient's ability to walk and run. A shoe lift may also relieve back pain caused by a smaller limb length discrepancy. Shoe lifts are inexpensive and can be removed easily if they are not effective.
. Surgical Treatment
In general, surgeries for limb length discrepancy are designed to do one of the following:
. Slow down or stop the growth of the longer limb
. Shorten the longer limb
. Lengthen the shorter limb
In children who are still growing, epiphysiodesis can be used to slow down or stop growth at one or two growth plates in the longer leg.
It is a relatively simple surgical procedure that can be performed in one of two ways:
. The growth plate may be destroyed by drilling or scraping it to stop further growth. The leg length discrepancy will gradually decrease as the opposite leg continues to grow and "catch up."
. Metal staples, or a metal plate with screws, may be placed around the sides of the growth plate to slow or stop growth. The staples are then removed once the shorter leg has "caught up."
The procedure is performed through very small incisions in the knee area, using x-rays for guidance. Proper timing is critical. The goal is to reach equal leg length by the time growth normally ends—usually in the mid to late teenage years.
Disadvantages of epiphysiodesis include:
. The possibility of a slight over- or under-correction of the limb length discrepancy
. The patient's adult height will be less than if the shorter leg had been lengthened
. Correction of a significant discrepancy using this technique may make the patient's body look slightly disproportionate because of the shorter leg
. Limb Shortening
In patients who are finished growing, the longer limb can sometimes be shortened to even out the leg lengths.
To do this, the doctor removes a section of bone from the middle of the longer limb, then inserts metal plates and screws or a rod to hold the bone in place while it heals.
Because a major shortening may weaken the muscles of the leg, limb shortening cannot be used for significant limb length discrepancies. In the femur (thighbone), a maximum of 3 inches can be shortened. In the tibia (shinbone), a maximum of 2 inches can be shortened.
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. Limb Lengthening
Because of their complexity, limb lengthening procedures are usually reserved for patients with significant discrepancies in length.
Lengthening can be performed either externally or internally.
. External lengthening. In this procedure, the doctor cuts the bone in the shorter leg into two segments, then surgically applies an "external fixator" to the leg. The external fixator is a scaffold-like frame that is connected to the bone with wires, pins, or both.
The lengthening process begins approximately 5 to 10 days after surgery and is performed manually. The patient or a family member turns the dial on the fixator several times each day.
When the bones are gradually pulled apart (distracted), new bone will grow in the space created. Muscles, skin and other soft tissues will adapt as the limb slowly lengthens.
The bone may lengthen 1 mm per day, or approximately 1 inch per month.
Lengthening may be slower in a bone that was previously injured. It may also be slower if the leg was operated on before. Bones in patients with potential blood vessel abnormalities, such as cigarette smokers, may also need to be lengthened more slowly.
The external fixator is worn until the bone is strong enough to support the patient safely. This usually takes about three months for each inch of growth. Factors such as age, health, smoking and participation in rehabilitation can affect the amount of time needed.
External limb lengthening requires:
. Meticulous cleaning of the area around the pins and wires
. Diligent adjustment of the frame several times daily
Potential risks and complications of external lengthening include:
. Infection at the site of wires and pins
. Stiffness of the adjacent joints
. Slight over- or under-correction of the bone's length
. Internal lengthening. In this procedure, the doctor cuts the bone in the shorter leg, then surgically implants an expandable metal rod in the bone. The rod is completely internal and lengthens gradually in response to the normal movements of the patient's limb.
As the rod lengthens, the bones are gradually pulled apart and new bone grows in the space created. The rod provides stability and alignment to the bone as it lengthens.
Because no external fixator is used in internal lengthening, there is less risk of infection—including the superficial infection that commonly occurs around pin sites.
Internal lengthening avoids the physical and psychological challenges that come with wearing an external fixator; however, it allows for less precise control over the rate of lengthening.
Both internal and external lengthening take several months to complete. Both procedures require:
. Regular follow-up visits to the doctor's office
. Extensive rehabilitation, including physical therapy and home exercise
A doctor experienced in limb lengthening techniques will talk with you about your treatment options and explain the risks and benefits of both internal and external limb-lengthening. Together, you and your doctor will decide which procedure, if any, is best for your child.
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After Limb Length Discrepancy
Recovery and Aftercare
After the operation, nursing staff teach patients how to clean and care for the skin around the pins that attach the external fixator to the limb (pinsite care). Patients are also shown how to recognize and treat early signs of infection and not to neglect pinsite care, which takes about 30 minutes every day until the apparatus is removed. It is very important in preventing infection from developing.
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.
In the case of leg lengthening surgery, hospitalization may require a week or longer. Intensive physical therapy is required to maintain a normal range of leg motion. Frequent visits to the treating physician are also required to adjust the external fixator and attentive care of the pins holding the device is essential to prevent infection. Healing time depends on the extent of lengthening.
A rule of thumb is that each 0.4 in (1 cm) of lengthening requires some 36 days of healing. A large variety of external fixators are now available for use. Today's fixators are very durable, and are generally capable of holding full weight. Most patients can continue many normal activities during the three to six months the device is worn.
Metal pins, screws, staples, rods, or plates are used in leg lengthening/shortening surgery to stabilize bone during healing. Most orthopedic surgeons prefer to plan to remove any large metal implants after several months to a year. Removal of implanted metal devices requires another surgical procedure under general anesthesia.
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.
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.
Bone lengthening is completely successful only 40% of the time and has a much higher rate of complications. Recovery time from leg lengthening surgery varies among patients, with the consolidation phase sometimes lasting a long period, especially in adults.
Generally speaking, children heal in half the time as it takes an adult patient. For example, when the desired goal is 1.5 in (3.8 cm) of new bone growth, a child will wear the fixation device for some three months while an adult will need to wear it for six months.