Surgical intervention involving leg length discrepancy usually aims at lengthening of the ipsilateral limb. Is contralateral limb shortening performed in certain critical situations?
Sure, the contralateral limb shortening is sometimes a good solution. In some cases it is even the method of choice, i.e. in congenital unilateral gigantism of the lower extremity, in cases of overgrowth after physis injuries in the past, in lumbar scoliosis with extreme pelvic tilt and functional lengthened limb,etc. In the usual cases of leg length discrepancy the shortening of the contralateral (healthy) limb should be done after a shared decision making with the patient, because the limb inequality may be eliminated but the patient will lose some of his/her height.
Dear Ziad
The leg length discrepancy can be treated by some ways and its necessary to select the patients in two groups: one that still has potential for bone growth and in adults.In patients with potential bone growth is preferable temporary blocking of bone growth (epiphysiodesis - this will depend on the real discrepancy and the potential for bone growth)) and those in adulthood is possible to perform bone lengthening (more morbidity and more complications) or the shortening of contralateral side ( (proportionality has to be evaluated between the trunk and lower limbs and discussed with the patient)
Dear Nelson, you are right. In children and adolescents with growth potential epiphysiodesis is a good option. On the other hand, it is a delicate procedure and should be planned and controlled with attention. There are some scales for the growth expectancy in boys and girls according to their age. Unfortunately, the values are average and the prognosis is not very exact in the individual case.
In adult patients the situation is different. Lengthening or shortening is possible in different ways.
There is a very interesting option which comes from the classic German orthopaedics. I have done it several times with success. It is appropriate for cases with limb inequality of up to 6-7 cm. If the extremity length discrepancy is mainly in the femur a tubular segment (i.e. 3 cm) can be taken from the longer femur and be transferred to the shorter femur after osteotomy at the same level (usually diaphysis). Then osteosynthesis with plates ot intramedullary nails is performed bilaterally. The problem is the duration of healing, time for loading, etc. I did not have any problems with my patients who were satisfied with the end result.
Dears Panayot and Nelson:
Thank you for your constructive and insightful answers.
Best
ZAF
Dear friends: thanks a lot for sharing information. For me in this situation and in children cases, I like to use a nice software program called: multiplier. It is free and you can download from apple store to your I phone. Then I can calculate how much the limb discrepancy will be at puberty ?
Either the case is congenital or developmental, you can calculate and plan exactly for everything. In case the discrepancy is 4 centimeters for example and this person will be above the average height after you calculate also his expected height at puberty from the same program, then you can have a choice either to do a contra lateral physiodesis ( the program will calculate for you the proper age to do physiodesis to compensate the LLD or you can plan for a shortening operation which is possible for up to 4 cm only..... Etc .
In case the LLD is greater than 4 cm, then you can have the option of contra lateral physiodesis + shortening of the contra lateral side or also doing a lengthening procedure of the short side. In adults, I will not add more than Nelson and Panayot wrote here. All the best
I have had experience with congenital hemihypertrophy with LLD, in which I performed what Dr Nelson described, excision of a tubular segment of the femur , about 4cm and an interlocked nailing. This man was a physician and specifically demanded shortening of the longer limb rather than lengthening of the shorter limb. Most of the time here, a shortening procedure is rather difficult to sell rather than a lengthening one due to the premium importance given to the overall height and its relation to self esteem.
Yes, contralateral limb shortening should be an option and may be preferable in those situations where the shortened limb is associated with contractures already.
Leg shortening as a valuable option in case of leg length discrepancy, especially if the shortening is located on the femoral side. The advantage is that the osteosynthesis is not producing a bony gap (as in femoral lengthening) thus healing normally is uneventful and easier as in case of lengthening. The disadvantage of course is loss of height but this topic should be discussed with the patient.
Has there been any publications about correction of leg length discrepancy via shortening?
There is a textbook from M.E Müller dealend with that Tonic which is extremely illustrative AND is showing the technique in Detail. If you can't geht it maybe you will also find Parts of it on the AO Homepage.
I had couple of patients with hypertrophic legs, where I performed shortening for 4cm. The principle could be - manipulate limb/bone with pathology. On the other hand Merle d'Aubignet has described method called equalisation, where in case of 8 cm femur (if I remember correctly) shortening he took 4 cm piece of bone from longer side and replaced it to shorter side. The disadvantage is, that one moment lengthening can be difficult and in this case you get both legs without weigthbearing ability. But you can draw up different variations. Good luck!
Merle d'Aubigne was always a MAESTRO but one Little risky.
Merry Chritsmas.
I would prefer epiphyseodesis of contralateral growing physis in adolescents. Could be temporary od permanent, prox. tibial od distal femoral od both - depends on remaining skeletal growth potency and desired amount of correction. I have a good experience!
I did 8 cases. It is indicated in tall boys when the discrepancy it is most of the femur and it is not severe. It is easier to shorten the femur than to lengthen it. The tecnique: I performed a subtrocanteric oblique osteotomy 2-3 cm its depends to to the discrepancy, then It is stabilized with a Grsse-Kempf nail with a screw in the proximal segment. Immediate full weight bearing. No complications, no nonunion, no Trendeleburg gait. Relatively simple and effective. I would like to publish the cases, but I have no time.