Limb length discrepancy can be congenital or acquired. It is defined as a difference in leg length of 2.5 cm or more. A short leg causes an awkward gait, increased energy expenditure, and back pain. Treatment depends on the severity and includes shoe lifts for mild cases and epiphysiodesis, shortening, or lengthening procedures for larger discrepancies. Limb lengthening uses either external fixators like the Ilizarov or internal devices to gradually lengthen the bone through the process of distraction osteogenesis, where the bone is slowly pulled apart to stimulate new bone growth. Treatment must be tailored based on the individual's age, growth remaining, and specific condition.

1. LIMB LENGTH DISCREPANCY
Presenter – Dr. Madhukar

2. • Limb length discrepancy or
anisomelia, Is defined as a
condition in which the
paired extremity limbs
have a noticeably unequal
length.

3. • Limb length discrepancy in lower extremity is
not only a cosmetic concern but also a
functional concern.
• The short leg gait
- is awkward
- increases energy expenditure because of the
excessive vertical rise and fall of pelvis.
- and may result in back pain from lon-standing
significant discrepncies

4. • It is noted that limb-length inequalitis of 0.5 to
2.0 cm are common in the normal,
asymptomatic population.
• Limb-length inequality of more than 2.5 cm
are considered to be significant.

5. ETIOLOGY
• Congenital :
- idiopathic unilateral hypo/hyperplasia
- hemiarthropathy (Russell-Silver Syndrome)
- congenital fibular deficiency (fibular hemimelia)
- congenital tibial deficiency (tibial hemimelia)
• Developmental :
- Infections damaging the physis,
- Asymetrical paralytic conditions (eg: poliomyelitis, cerebral
palsy)
- Tumors or tumor-like conditions(enchondroma,
osteochondroma) that affect bone growth by stimulating
asymetrical growth.
• Post traumatic :
- Malunions and Truma affecting the physis.

6. Mechanism of Compensation
• A child with LLD usually compensates better than an adult.
• Check for specific compensation used the patient to level out
the difference in height.
– Pronation in the ankle of the longer leg
– Plantar flexion in the shorter leg
– Knee and hip extension of the shorter or flexion in the longer
leg
– If the leg is left uncompensated, the anterior and posterior iliac
spine on the side of the short leg can be lower which may
result in scoliosis.
– Increased muscle activity in several muscle groups

7. Effect on spine
• Low back pain
• Increased incidence of scoliosis
• Severity depends on
- related severity of LLD
- uncompensated or uncorrected
- Onset of age

8. Effect on hip
• Pelvic obliquity
• A longer leg might be a predisposing factor in
Osteoarthritis (OA).
• Combined with an increased tone in hip
abductors caused by elongated distance
between origin and insertion and an increased
ground reaction force puts the longer at risk.

9. Effect on gait
• Increased energy
• Increased force of impact

10. Effect on long bones
• Greater incidence of stress fractures in tibia,
matatarsals and femur of longer leg appear
consistent with the greater forces emitted
through the longer leg.

11. Evaluation
• History
• Examination
• Imaging
- STANDING ORTHORADIOGRAPH
- SCANOGRAMA

12. History
• Congenital or Developmental
• To determine Casue
• To determine deformity
• Onset and mode of deformity

13. Examination
• Clinical evaluation should include assessment
for any rotational and angular deformities,
foot height differences, scoliosis, pelvic
obliquity and joint mobility and function.
• In certain paralytic conditions , particularly in
spastic diplegia, flexion contracture of the
knee and hip make the limb appear shorter
than it really is on clinical and radiographic
examinations.

14. • Wood block test:
- with the patient standing, add blocks(known
weights) under the short leg until the pelvis is
level, then measure the blocks to determine
the discrepancy.
- block testing is considered the best initial
screening method.
- However, asymmetrical pelvic development or
pelvic obliquity can cause miscalculation.

16. • Leg-length measurement:
- Apparent length
- True length

17. Radiographs
• Commonly used techniques for measuring the
limb-length discrepancy
1. Standing orthoradiographs
2. Scanogram
3. Orthoroentgenogram
4. CT Scanogram

18. • Orthoradiograph is made on a long cassette
that includes hip,knee and ankle on a single
exposure.
• Scanogram uses separate exposures of the
hip, knee and ankle, so there is little parrallax
errror. But exposure is more in scanogram.

19. Orthoroentgenogram
• It is a radiographic
study used to evaluate
anatomic limb-length
and calculate limb-
length discrepancies.
• This study utilises a long
ruler placed on the film,
and three radiographs
including bilateral hips,
knees and ankles.

20. CT Scanogram
• These have been praposed as an improvement
over standard scanograms because the
radiation exposure is less and accuracy is not
compramised.
• On lateral CT Scanograms accurate
mesurement can be made of even the limb
with flexion deformity.

22. Skeletal age
• It is an important factor to include when making
treatment decisions.
• GREULICH-PYLE ATLAS is used for determining
the skeletal age.
• A view of left wrist is obtained to estimate
skeletal age from the chart.
• This is however unnecessary for children younger
than 5 yrs of age because the skeletal and
chronological ages are not significantly different
in these children.

23. Techniques for predicting growth
remaining
• Two techniques are widely used to predict the
growth and help surgeons determine the
timing of limb equalization procedures.
1. Green-Anderson growth-remaining chart.
2. Moseley straight line graph.

24. Green & Anderson chart
• Proper use of this chart requires the clinician
to estimate the percentage of growth
inhibition for the patient by taking two
interval measurements seperated by at least 3
months.
• The growth difference the normal and the
involved limb is multiplied by 100 , and the
result is divided by the growth of normal limb.

25. Moseley straight-line graph
• Moseley simplified the Green-Anderson chart
by mathematically manipulating the original
data to allow it to fit on a straight line graph
that is visually graphic and easier to apply.
• This avoids the need of mathematical
calculations of growth inhibition and provides
a ready prediction of the results of
epiphysiodesis, lengthening and shortening.

26. • In this 3 measurements are taken every visit
1. Length of normal limb
2. Length of involved limb
3. Skeletal age
• The difference between the slopes of normal
and involved limb is the growth inhibition.

30. Other techniques
• Menelaus method
• Paley et al. multiplier method

31. Treatment
• Treatment of limb-length discrepancy must be
tailored to the specific conditions and needs of
the individual patients.
• Treatment plans can be formulated only after a
careful evaluation that includes assessment of
the chronological and skeletal ages of the patient,
the current and the predicted discrepancy in the
limb lengths, the predicted adult height, the
cause of the discrepancy, the functional status of
the joints, and the social and psychological
background of the patient and family.

32. • Four types of treatment are available for limb-
length equalization
1- Shoe rise or prosthetic conversion
2- Epiphyseiodesis of long leg
3- Shortening of long leg(in older patients)
4- lengthening of the short leg

33. Shoe lift
• For Discrepancies of 1.5cm or less no
treatment is necessary.
• Upto 1cm shoe lift can be provided to wear
inside the shoe.
• For 2 to 4cm difference shoe lift on the
outside of the shoe are necessary.
• For > 5cm shoe rises are unsightly and
unstable and may require additional uprights
or

34. Epiphysiodesis
• It is used to describe arrest of growth at a particular
physis.
• Recommended for shortening upto 5cm
• This can be performed percutaneous and open.
• Very low morbidity , simple , fast recovary and low
complication rate.
• Disadvantages are
- Normal limb is operated rather than pathological limb
- The resulting bony proportions may be cosmetically
displeasing after shortening
- Final height after the procedure may be unacceptably low

35. Phemister technique (JBJS 1933)
• This technique uses
removal of a
rectangular block of
bone medially and
laterally at the level of
the physis that is then
replaced in a 180
degree rotated position.

36. Epiphyseal stapling (Blount technique)

37. PERCUTANEOUS
EPIPHYSIODESIS
• Described by Mataizeau et al. using
transphyseal screws (PETS)

38. TENSION PLATE EPIPHYSIODESIS
• This is a open technique.
• This technique is largely reserved for
hemiepiphysiodesis in angular corrections.
• But it can be used for complete epiphysiodesis if
implants are used on both sides of the physis.
• This technique also has the advantage of
potential growth resumption with implant
removal; however,restoration of normal growth
often is unpredictable after implant removal, and
careful timing of epiphysiodesis is still important.

39. • Most of these plating systems are nonlocking,
which allows some degree of screw divergence
within the plate as the physis continues to grow.
• It is likely that growth arrest does not occur until
maximal screw divergence is reached.
• Therefore, it is advisable to place the screws in a
divergent fashion at the time of implantation to
allow growth arrest to occur as quickly as
possible.
• Usually 4 holed plates are used rather than 2.

41. Canake et al. technique

42. Limb shortening
• Usually done in skeletally mature patients with
discrepancy > 2cm who can accept the loss of
stature necessary to equalize the limbs.
• In Femur – 5-6 cm is the max length that can be
removed without seriously affecting muscle
function
• In tibia – 2-3cm
• Shortening of femur is more preferred due to the
high risk of compartment syndrome in tibia due
less muscle coverage.

43. Proximal femoral metaphyseal
shortening
• Proximal lateral incision
• Mark the bone to control
rotation
• Remove the marked
segment,leave a spike of
medial cortex and lesser
trochanter intact to act as
butterss.
• Distal fragment is brought into
direct apposition with
proximal mad osteosythesis
plate is used to achive
compression.

44. Distal femoral metaphyseal osteotomy
• Same as proximal
• Lateral incision
• Proximal osteotomy cut is
made and then distally
• For added stability medial
spike is preserved
• Impact two fragments
and blade plate is applied
under compression.

45. Proximal tibial metaphyseal shortening
• Lateral incision, resect a portion of
fibula at the junction of th
proximal and middle thirds.
• Another anterior incision to
expose the proximal tibia.
• Resect desired amount of bone
below tibial tuberosity
• T plate is applied with after
holding two ends of bone under
compression.
• Perform prophylactic fasciotomy.

46. Tibial diaphyseal shortening
• By broughton,olney and menelaus
• Longitudinal incision over the
anteromedial surface of tibia.
• Subperiosteal dissection
• Step-cut osteotomy
• Through another incision same
amount of bone is removed from
fibula midshaft.
• Fix the step-cut osteotomy with
two lag screws.
• Only Indicated in skeletally
immature patients.

47. Closed femoral diaphyseal shortening

49. Limb lengthening
• Device for gradual lengthening
– Unilateral fixator
– Circular ring fixator (Ilizarov, Taylor spatial
frame )
• Combined internal and external fixation
– (Lengthening over IM Nailing)
• Totally implantable lengthening device
– Albizzia nail
– ISKD(intramedullary skeletal kinetic device)

50. Transiliac lengthening
• By Mills and Hall
• Anterior ilioinguinal approach
• Perform Osteotomy from sciatic notch to
anterior inferior iliac spine
• Take a full thickness trapezoid shaped block of
iliac crest
• Wedge this iliac graft into the distraction site
and hold it with two large, threaded
Steinmann pins.

52. Tibia Lengthening
• BY DEBASTIANI ET AL.
• Uses orthofix lengthening devices

53. • This technique uses the principle of lengthening
by callotasis ( or low-energy corticotomy followed
by gradual distraction of the bone fragments with
a mechanical apparatus).
• Distraction should begin after a brief latent
period of 1 – 3 weeks to allow for early callus
formation.
• The rate of distraction should be approx. 1mm
per day divided over four 0.25mm increments.

54. Ilizarov method
• Principle:
– It is based on the principle of distraction
osteogenesis.
– A bone that has been cut during surgery are
gradually pulled apart (distraction)
– Leads to new bone formation (osteogenesis)
at the site of lengthening

55. • Advantage of ilizarov over monolateral fixators is the
ability to gradually correct angular or rotational
deformities by adjusting the configuration of the frame
witout use of anesthesia.
• 3-7 days of latency period allows development of callus
at the site of corticotomy which is then followed by
distraction period.
• After lengthening, the limb is still in external fixator
until adequate consolidation of the new bone has
occured.
• Typically, consolidation period is approximately twice
the distraction period.

57. Taylor spatial frame
• Used for deformity correction and
lengthening.
• A basic system with two rings and
six telescopic rods with special link
joints.
• This frame also uses the slow
correction principles of ilizarov but
adds a six axis deformity analysis
incorporated into a computer
program.
• This program has show a steep
learning curve has high cost.

58. Femur lengthening
• By DEBASTIANI ET AL.
• Perform a corticotomy just distal to the ilio-psoas insertion.
• Incise the anterior thigh skin longitudinally between
sartorius and tensor fascia lata muscle and then incise the
periosteum longitudinally and elevate it.
• Now drill a series of 4.8mm unicortical holes in anterior
2/3rd circumfarence of femur of 1cm depth not entering the
medullary cavity.
• Use a thin osteotome to connect the holes and the flex the
femur at the corticotomy to crack the posterior cortex to
complete the corticotomy.
• Orthofix lengthening device is then applied ( use six pins for
femur to gain stability and to resist varus deviation )

60. Femoral lengthening over
intramedullary nail (ISKD)
• By COLE, PALEY AND DAHIL
• ISKD - Intramedullary Skeletal Kinetic Distractor

61. Complications
1. Pin track infections
2. Muscular problems
3. Joint problems
4. Neurovascular problems
5. Bone problems

62. THANK YOU