Overview
The type of surgery depends on the type of problem. Outpatient procedures may be used to alter the growth of the limb. This is often done through small incisions. If an outpatient procedure is done, your child can continue with most regular activities. Other times, surgery may be very involved and require the use of an external device that is attached to the limb with pins and wires. This device may be left on for months to correct the deformity or lengthen the leg. If this type of surgery is required, your child will be making weekly visits to Cincinnati Children's.
Causes
Leg discrepancy can develop from a medical issue in any portion of the femur or tibia. One leg may lengthen, but leg shortening is much more common. Factors that can cause leg length discrepancy include inherited growth deficiencies. Infections. A bone infection can cause delayed growth in the affected limb. Injury. If your child breaks a leg, it may be shorter once it heals. This is most likely to happen if the fracture or break was complicated, an open fracture, or an injury that affected the growth plate near the end of the bone. Alternatively, a break can cause bones to grow faster after healing, making a leg longer. Tumors. Legg-Calve-Perthes disease. This is a condition that affects the ball (femoral head) of the hip joint. The femoral head may be friable and damage easily, sometimes leading to shortening of the thigh bone. Hemihypertrophy. In children with this condition, one side of the body grows more quickly than the other. Vascular malformations. These are abnormal clusters of veins and arteries that can form close to the bone and stimulate growth. Juvenile arthritis. Inflammation from arthritis can stimulate growth in the affected leg and cause discrepancy.
Symptoms
Children whose limbs vary in length often experience difficulty using their arms or legs. They might have difficulty walking or using both arms to engage in everyday activities.
Diagnosis
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
Heel lifts Raise the heel on the shorter leg. It is applied either to the heel of the custom orthotic or to the inside of the shoe under the insole at the heel. Generally if the discrepancy is greater than 3/8 of an inch, the modification is applied externally on the footwear. Custom made orthotics help to provide proper support and alignment to the foot, controlling conditions such as over pronation. Orthopedic Footwear, properly fitted, to which a lift might be applied inside or out.
Surgical Treatment
Surgical operations to equalize leg lengths include the following. Shortening the longer leg. This is usually done if growth is already complete, and the patient is tall enough that losing an inch is not a problem. Slowing or stopping the growth of the longer leg. Growth of the lower limbs take place mainly in the epiphyseal plates (growth plates) of the lower femur and upper tibia and fibula. Stapling the growth plates in a child for a few years theoretically will stop growth for the period, and when the staples were removed, growth was supposed to resume. This procedure was quite popular till it was found that the amount of growth retarded was not certain, and when the staples where removed, the bone failed to resume its growth. Hence epiphyseal stapling has now been abandoned for the more reliable Epiphyseodesis. By use of modern fluoroscopic equipment, the surgeon can visualize the growth plate, and by making small incisions and using multiple drillings, the growth plate of the lower femur and/or upper tibia and fibula can be ablated. Since growth is stopped permanently by this procedure, the timing of the operation is crucial. This is probably the most commonly done procedure for correcting leg length discrepancy. But there is one limitation. The maximum amount of discrepancy that can be corrected by Epiphyseodesis is 5 cm. Lengthening the short leg. Various procedures have been done over the years to effect this result. External fixation devices are usually needed to hold the bone that is being lengthened. In the past, the bone to be lengthened was cut, and using the external fixation device, the leg was stretched out gradually over weeks. A gap in the bone was thus created, and a second operation was needed to place a bone block in the gap for stability and induce healing as a graft. More recently, a new technique called callotasis is being use. The bone to be lengthened is not cut completely, only partially and called a corticotomy. The bone is then distracted over an external device (usually an Ilizarov or Orthofix apparatus) very slowly so that bone healing is proceeding as the lengthening is being done. This avoids the need for a second procedure to insert bone graft. The procedure involved in leg lengthening is complicated, and fraught with risks. Theoretically, there is no limit to how much lengthening one can obtain, although the more ambitious one is, the higher the complication rate.
The type of surgery depends on the type of problem. Outpatient procedures may be used to alter the growth of the limb. This is often done through small incisions. If an outpatient procedure is done, your child can continue with most regular activities. Other times, surgery may be very involved and require the use of an external device that is attached to the limb with pins and wires. This device may be left on for months to correct the deformity or lengthen the leg. If this type of surgery is required, your child will be making weekly visits to Cincinnati Children's.
Causes
Leg discrepancy can develop from a medical issue in any portion of the femur or tibia. One leg may lengthen, but leg shortening is much more common. Factors that can cause leg length discrepancy include inherited growth deficiencies. Infections. A bone infection can cause delayed growth in the affected limb. Injury. If your child breaks a leg, it may be shorter once it heals. This is most likely to happen if the fracture or break was complicated, an open fracture, or an injury that affected the growth plate near the end of the bone. Alternatively, a break can cause bones to grow faster after healing, making a leg longer. Tumors. Legg-Calve-Perthes disease. This is a condition that affects the ball (femoral head) of the hip joint. The femoral head may be friable and damage easily, sometimes leading to shortening of the thigh bone. Hemihypertrophy. In children with this condition, one side of the body grows more quickly than the other. Vascular malformations. These are abnormal clusters of veins and arteries that can form close to the bone and stimulate growth. Juvenile arthritis. Inflammation from arthritis can stimulate growth in the affected leg and cause discrepancy.
Symptoms
Children whose limbs vary in length often experience difficulty using their arms or legs. They might have difficulty walking or using both arms to engage in everyday activities.
Diagnosis
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
Heel lifts Raise the heel on the shorter leg. It is applied either to the heel of the custom orthotic or to the inside of the shoe under the insole at the heel. Generally if the discrepancy is greater than 3/8 of an inch, the modification is applied externally on the footwear. Custom made orthotics help to provide proper support and alignment to the foot, controlling conditions such as over pronation. Orthopedic Footwear, properly fitted, to which a lift might be applied inside or out.
Surgical Treatment
Surgical operations to equalize leg lengths include the following. Shortening the longer leg. This is usually done if growth is already complete, and the patient is tall enough that losing an inch is not a problem. Slowing or stopping the growth of the longer leg. Growth of the lower limbs take place mainly in the epiphyseal plates (growth plates) of the lower femur and upper tibia and fibula. Stapling the growth plates in a child for a few years theoretically will stop growth for the period, and when the staples were removed, growth was supposed to resume. This procedure was quite popular till it was found that the amount of growth retarded was not certain, and when the staples where removed, the bone failed to resume its growth. Hence epiphyseal stapling has now been abandoned for the more reliable Epiphyseodesis. By use of modern fluoroscopic equipment, the surgeon can visualize the growth plate, and by making small incisions and using multiple drillings, the growth plate of the lower femur and/or upper tibia and fibula can be ablated. Since growth is stopped permanently by this procedure, the timing of the operation is crucial. This is probably the most commonly done procedure for correcting leg length discrepancy. But there is one limitation. The maximum amount of discrepancy that can be corrected by Epiphyseodesis is 5 cm. Lengthening the short leg. Various procedures have been done over the years to effect this result. External fixation devices are usually needed to hold the bone that is being lengthened. In the past, the bone to be lengthened was cut, and using the external fixation device, the leg was stretched out gradually over weeks. A gap in the bone was thus created, and a second operation was needed to place a bone block in the gap for stability and induce healing as a graft. More recently, a new technique called callotasis is being use. The bone to be lengthened is not cut completely, only partially and called a corticotomy. The bone is then distracted over an external device (usually an Ilizarov or Orthofix apparatus) very slowly so that bone healing is proceeding as the lengthening is being done. This avoids the need for a second procedure to insert bone graft. The procedure involved in leg lengthening is complicated, and fraught with risks. Theoretically, there is no limit to how much lengthening one can obtain, although the more ambitious one is, the higher the complication rate.