Leg Length Discrepancy Producing Hip Pain
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 length discrepancies can be caused by: hip and knee replacements, lower limb injuries, bone diseases, neuromuscular issues and congenital problems. Although discrepancies of 2 cm or less are most common, discrepancies can be greater than 6 cm. People who have LLD tend to make up for the difference by over bending their longer leg or standing on the toes of their shorter leg. This compensation leads to an inefficient, up and down gait, which is quite tiring and over time can result in posture problems as well as pain in the back, hips, knees and ankles.
Symptoms
Faulty feet and ankle structure profoundly affect leg length and pelvic positioning. The most common asymmetrical foot position is the pronated foot. Sensory receptors embedded on the bottom of the foot alert the brain to the slightest weight shift. Since the brain is always trying to maintain pelvic balance, when presented with a long left leg, it attempts to adapt to the altered weight shift by dropping the left medial arch (shortening the long leg) and supinating the right arch to lengthen the short leg.1 Left unchecked, excessive foot pronation will internally rotate the left lower extremity, causing excessive strain to the lateral meniscus and medial collateral knee ligaments. Conversely, excessive supination tends to externally rotate the leg and thigh, creating opposite knee, hip and pelvic distortions.
Diagnosis
A systematic and well organized approach should be used in the diagnosis of LLD to ensure all relevant factors are considered and no clues are overlooked which could explain the difference. To determine the asymmetry a patient should be evaluated whilst standing and walking. During the process special care should be used to note the extent of pelvic shift from side to side and deviation along the plane of the front or leading leg as well as the traverse deviation of the back leg and abnormal curvature of the spine. Dynamic gait analysis should be conducted during waling where observation of movement on the sagittal, frontal and transverse planes should be noted. Also observe head, neck and shoulder movements for any tilting.
Non Surgical Treatment
The key to treatment of LLD in a child is to predict what the discrepancy is at maturity. If it is predicted to be less than 2 cm., no treatment is needed. Limb length discrepancies of up to 2 or 2.5 cm. can be compensated very well with a lift in the shoe. Beyond 2.5 cm., it becomes increasingly difficult to compensate with a left in the insole. Building up the shoe becomes uncosmetic and cumbersome, and some other way of compensating for the discrepancy becomes necessary. The treatment of LLD is long-term treatment, and involves the physician and patient?s family working together as a team. The family needs to weigh the various options available. If leg lengthening is decided on, the family needs to understand the commitment necessary to see it through. The treatment takes 6 months to a year for completion, and complications can happen. But when it works, the results are gratifying.
functional leg length discrepancy treatment
Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
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 length discrepancies can be caused by: hip and knee replacements, lower limb injuries, bone diseases, neuromuscular issues and congenital problems. Although discrepancies of 2 cm or less are most common, discrepancies can be greater than 6 cm. People who have LLD tend to make up for the difference by over bending their longer leg or standing on the toes of their shorter leg. This compensation leads to an inefficient, up and down gait, which is quite tiring and over time can result in posture problems as well as pain in the back, hips, knees and ankles.
Symptoms
Faulty feet and ankle structure profoundly affect leg length and pelvic positioning. The most common asymmetrical foot position is the pronated foot. Sensory receptors embedded on the bottom of the foot alert the brain to the slightest weight shift. Since the brain is always trying to maintain pelvic balance, when presented with a long left leg, it attempts to adapt to the altered weight shift by dropping the left medial arch (shortening the long leg) and supinating the right arch to lengthen the short leg.1 Left unchecked, excessive foot pronation will internally rotate the left lower extremity, causing excessive strain to the lateral meniscus and medial collateral knee ligaments. Conversely, excessive supination tends to externally rotate the leg and thigh, creating opposite knee, hip and pelvic distortions.
Diagnosis
A systematic and well organized approach should be used in the diagnosis of LLD to ensure all relevant factors are considered and no clues are overlooked which could explain the difference. To determine the asymmetry a patient should be evaluated whilst standing and walking. During the process special care should be used to note the extent of pelvic shift from side to side and deviation along the plane of the front or leading leg as well as the traverse deviation of the back leg and abnormal curvature of the spine. Dynamic gait analysis should be conducted during waling where observation of movement on the sagittal, frontal and transverse planes should be noted. Also observe head, neck and shoulder movements for any tilting.
Non Surgical Treatment
The key to treatment of LLD in a child is to predict what the discrepancy is at maturity. If it is predicted to be less than 2 cm., no treatment is needed. Limb length discrepancies of up to 2 or 2.5 cm. can be compensated very well with a lift in the shoe. Beyond 2.5 cm., it becomes increasingly difficult to compensate with a left in the insole. Building up the shoe becomes uncosmetic and cumbersome, and some other way of compensating for the discrepancy becomes necessary. The treatment of LLD is long-term treatment, and involves the physician and patient?s family working together as a team. The family needs to weigh the various options available. If leg lengthening is decided on, the family needs to understand the commitment necessary to see it through. The treatment takes 6 months to a year for completion, and complications can happen. But when it works, the results are gratifying.
functional leg length discrepancy treatment
Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
