Pelvic limb inequalities

• Leg length inequalities
• Etiology
• Treatment

Leg length inequalities

Leg length inequalities are a frequent concern for parents and also a commonly encountered finding during the clinical examination performed by the orthopedic doctor. Often asymptomatic, it should be kept in mind that treatment for this deformity can range from observation and periodic monitoring to extensive surgical interventions performed in several stages, or even amputation and prosthetic fitting, depending on the severity of the inequality and the functionality of the affected limb.
The dynamics of bone growth are particular in the management of leg length inequalities in children, being variable over time: rapid in the first years of life, followed by a period of stability in which growth is slow, until the first signs of puberty appear, after which the bones gradually reach their final size.
Longitudinal growth of long bones occurs through the growth cartilage, also called the physis. This is responsible for endochondral ossification and has different activity depending on its location on the bone. Thus, the percentage of longitudinal growth at the level of the femur is 30% through the proximal (upper) physis and 70% through the distal (lower) one; over time, at the level of the tibia, 55% of the length growth is attributed to the upper cartilage and 45% to the distal one.
The challenge for the pediatric orthopedic doctor is to estimate, with as much accuracy as possible, the inequality between limb lengths at the end of growth, thus establishing the optimal therapeutic approach. Several consultations are necessary for the clinical and radiological assessment of the leg length inequality, the cause that led to this condition, as well as the evaluation of its progression until the end of growth.

Etiology

- Congenital malformations: femoral/tibial hypoplasia, femoral/tibial aplasia, phocomelia, tibial hemimelia, congenital pseudarthrosis.
- Asymmetric neurological impairment: hemimyelomeningocele, poliomyelitis, hemiparesis.
- Tumors: enchondroma, osteochondroma, bone cyst, neurofibromatosis, hemangiomatosis, osteoid osteoma.
- Infections: osteomyelitis, osteoarthritis.
- Irradiation. 
- Rickets. 
- Dwarfism. 
- Blount's disease, Legg-Calve-Perthes disease. 
- Trauma: affecting the growth cartilage – causes shortening or angulation; femoral/tibial diaphyseal fractures – cause lengthening of the affected limb.
- Hypertrophy in the context of Klippel-Trenaunay syndrome, Beckwith-Wiedemann syndrome, Proteus syndrome.

Treatment

Social and psychological factors
Before starting treatment, the therapeutic options, their results, and their complications must be discussed with the patient and their family. The patient's understanding, acceptance, and compliance throughout the treatment period are necessary. At the same time, it is important for the family to understand that treatment of leg length inequalities, especially through lengthening of the affected segment, requires a long period of time and that they will have an active role in carrying it out.

Estimating the final inequality at the end of growth
Estimating the final inequality at the end of growth is crucial for establishing treatment, and several examinations of the patient are necessary in order to achieve the greatest possible accuracy.

Treatment options
Inequalities smaller than 2 cm are most often asymptomatic; they are relatively common in the population, so only periodic monitoring is needed to detect any potential progression or complication.
A shoe lift should be considered when the inequality exceeds 2 cm and the patient walks on the tip of the shorter (equinus) foot.
An orthopedic boot is used in cases of shortening of 3-6 cm, as it better stabilizes the foot.
Temporary orthopedic compensation should be applied to patients awaiting surgery in order to avoid the occurrence of complications.
Epiphysiodesis: consists of ablation of the growth cartilage of the longer limb; it should be considered when the predicted final inequality is greater than 2 cm.
Surgical shortening of the longer limb is performed in patients with a mature skeleton with an inequality between 2-5 cm at the femur, or 2-3 cm at the tibia.
Limb lengthening by mechanical means can be performed acutely for a femoral shortening of 2-4 cm, or 2-3 cm on the tibia.
Combined techniques: shortening the longer segment by half the difference and acute lengthening of the short one.
Progressive lengthening with an external fixator, in inequalities exceeding 4 cm, the method of choice for patients who also have an axial deformity requiring correction.
Hybrid lengthening techniques with an external fixator combined with internal fixation using intramedullary rods, which have the advantage that the external fixator can be removed immediately after the distraction phase.
Expandable rods are the newest method for bone growth and consist of implanting intramedullary fixation devices capable of performing distraction (lengthening) using radio waves or electromagnetic field activation to control the rhythm and rate of lengthening. They have the advantage of a less invasive intervention – minimal postoperative scarring, lower risk of infection, and correction controlled by the doctor.

Contraindications
Lengthening: inequalities smaller than 3 cm, predicted shortening that cannot be compensated through lengthening, patients at risk of neurovascular injury or with poor bone quality, neurofibromatosis, irradiation.
Shortening: very young patients, patients presenting shortening >5% of the normal length (4 cm) in the apparently healthy limb, epiphysiodesis as the sole method for correcting inequalities greater than 8 cm; epiphysiodesis performed at too young an age, which will lead to a reverse inequality, or performed after the optimal time, which will fail to equalize the limbs.
External fixator: unstable joints above and below the segment to be lengthened, non-compliant patient, inadequate care (risk of infection).

What does Centrokinetic offer you if you have a leg length inequality?

• an accurate diagnosis through a clinical medical examination and imaging investigations
• a highly specialized team
• proper coordination, with children or adults able to benefit from consultations in neurology, orthopedics, and medical recovery.

IF YOU DON'T ALREADY KNOW US

Centrokinetic is the most high-performing medical clinic dedicated to osteoarticular conditions, organized into several dedicated departments:

• Orthopedics: a department made up of a highly experienced team of orthopedic doctors, led by Dr. Andrei Ioan Bogdan, senior physician in orthopedics-traumatology, with surgical activity at Floreasca Emergency Clinical Hospital and at Medlife Orthopedic Hospital, specialized in sports traumatology and in ankle and foot surgery.
• Pediatric orthopedics, where we treat children's sports conditions (ligament and meniscus injuries), spinal deformities (scoliosis, kyphosis, hyperlordosis), and foot deformities (hallux valgus, hallux rigidus, clubfoot, flat valgus foot, cavus foot).
• Neurology, performing consultations and EMG within the department. The medical team is completed by dr. Mardare, who received specialized training at the University of Oxford in spinal surgery.
• Medical recovery, for children and adults, the department being led by one of the most experienced doctors in the field, senior lecturer dr. Tache Georgiana. The department is specialized in the recovery of performance athletes, in spinal conditions, and in the recovery of children with neurological and traumatic conditions.
• Medical imaging, the clinic being equipped with ultrasound and MRI, dedicated to musculoskeletal conditions. We take pride in our medical team of radiologists, made up of dr. Ghiea Sorin, dr. Pantu Cosmin, dr. Florescu Nicoleta, specialized in musculoskeletal imaging.

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