Surgical options in leg length discrepancy treatment include procedures to lengthen the shorter leg, or shorten the longer leg. Your child's physician will choose the safest and most effective method based on the aforementioned factors. No matter the surgical procedure performed, physical therapy will be required after surgery in order to stretch muscles and help support the flexibility of the surrounding joints. Surgical shortening is safer than surgical lengthening and has fewer complications. Surgical procedures to shorten one leg include removing part of a bone, called a bone resection. They can also include epiphysiodesis or epiphyseal stapling, where the growth plate in a bone is tethered or stapled. This slows the rate of growth in the surgical leg.
There are many causes of leg length discrepancy. Structural inequality is due to interference of normal bone growth of the lower extremity, which can occur from trauma or infection in a child. Functional inequality has many causes, including Poliomyelitis or other paralytic deformities can retard bone growth in children. Contracture of the Iliotibial band. Scoliosis or curvature of the spine. Fixed pelvic obliquity. Abduction or flexion contraction of the hip. Flexion contractures or other deformities of the knee. Foot deformities.
Many people walk around with LLD?s of up to 2 cm. and not even know it. However, discrepancies above 2 cm. becomes more noticeable, and a slight limp is present. But even up to 3 cm. a small lift compensates very well, and many patients are quite happy with this arrangement. Beyond 3 cm. however, the limp is quite pronounced, and medical care is often sought at that point. Walking with a short leg gait is not only unsightly, but increases energy expenditure during ambulation. It could also put more stress on the long leg, and causes functional scoliosis. Where the discrepancy is more severe, walking becomes grotesque or virtually impossible.
The doctor carefully examines the child. He or she checks to be sure the legs are actually different lengths. This is because problems with the hip (such as a loose joint) or back (scoliosis) can make the child appear to have one shorter leg, even though the legs are the same length. An X-ray of the child?s legs is taken. During the X-ray, a long ruler is put in the image so an accurate measurement of each leg bone can be taken. If an underlying cause of the discrepancy is suspected, tests are done to rule it out.
Non Surgical Treatment
Internal heel lifts: Putting a simple heel lift inside the shoe or onto a foot orthotic has the advantage of being transferable to many pairs of shoes. It is also aesthetically more pleasing as the lift remains hidden from view. However, there is a limit as to how high the lift can be before affecting shoe fit. Dress shoes will usually only accommodate small lifts (1/8"1/4") before the heel starts to piston out of the shoe. Sneakers and workboots may allow higher lifts, e.g., up to 1/2", before heel slippage problems arise. External heel lifts: If a lift of greater than 1/2" is required, you should consider adding to the outsole of the shoe. In this way, the shoe fit remains good. Although some patients may worry about the cosmetics of the shoe, it does ensure better overall function. Nowadays with the development of synthetic foams and crepes, such lifts do not have to be as heavy as the cork buildups of the past. External buildups are not transferable and they will wear down over time, so the patient will need to be vigilant in having them repaired. On ladies' high-heel shoes, it may be possible to lower one heel and thereby correct the imbalance.
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Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.