Instantaneous leg length discrepancy determination by "thigh-leg" technique

Reactive scoliosis: a challenging phenomenon in adolescent patients with hip arthritis

Functional limb length discrepancy (LLD) in adolescents can result from soft tissue contracture following long-standing hip disease. We present a case of a 13-year-old girl with difficulty in ambulation due to right hip pain and LLD. Radiographs revealed severe arthritis of right hip with signs of avascular necrosis of the femoral head. The patient had developed reactive scoliosis of lumbar spine along with pelvic obliquity. After failing conservative management, total hip arthroplasty (THA) without attempting to equalize LLD was performed. At 6-month follow-up, patient was pain free with full range of motion and her functional LLD was completely resolved. In such adolescent patients, reactive scoliosis of spine is reversible, and with no evidence of true LLD, THA without correcting LLD should be the right choice.

Evaluation of the Child with Short Stature

Orthopedic surgeons frequently encounter short statured patients. A systematic approach is needed for proper evaluation of these children. The differential diagnosis includes both proportionate and disproportionate short stature types. A proper history and physical examination and judicious use of plain film radiography will establish the diagnosis in most cases. In addition to the orthopedic surgeon, most of these patients will also be evaluated by other specialists, including endocrinologists and geneticists. This article provides an overview of the evaluation of the child with short stature and offers several illustrative examples.

Are differences in leg length predictive of lateral patello-femoral pain?

BACKGROUND AND PURPOSE

Lateral patello-femoral pain can shorten an athletic career and generally decrease an individual's physical activity and functional level, such as preventing stair climbing and reducing the ability to rise from a chair. Leg length inequality is associated with patello-femoral pain. A leg length test that best distinguishes the difference between people who have lateral patello-femoral pain and those who do not would have clinical utility. The purpose of the present study was, first, to determine if unilateral, lateral patello-femoral pain was associated with the longer leg when inequality of leg lengths existed and, second, to determine if leg length direct measurement, indirect measurement or quadriceps angle (Q angle) could correctly classify participants according to the presence or absence of patello-femoral pain.

METHOD

The study used an ex post facto, two-group quasi-experimental design. A volunteer sample of 52 participants (14 males, 38 females), ranged in age from 18 to 52 years. Three methods were used to measure leg lengths: palpation meter (PALM) on anterior superior iliac spines (ASIS) while participants maintained centred weight-bearing position on a high resolution pressure mat; tape measurement from ASIS to medial malleolus (supine); tape measurement from ASIS to lateral malleolus (supine). Additionally, Q angle was measured in supine position. Patellar grind test, medial retinacular and lateral patellar palpation screened for patello-femoral pain.

RESULTS

Logistic regression analysis determined correctness of membership in painful and non-painful patello-femoral groups. The PALM method of indirect measurement of leg length differences overall correctly classified approximately 83 % of the participants. Tape measure to medial and lateral malleoli as well as Q angle did not yield significant results.

CONCLUSION

The results suggested that the PALM method of measuring leg length differences may have clinical utility in differentiating between patients who are likely to sustain patello-femoral pain syndrome and those who will not.

Limb length inequality: clinical implications for assessment and intervention

The purpose of this paper is to review relevant literature concerning limb length inequalities in adults and to make recommendations for assessment and intervention based on the literature and our own clinical experience. Literature searches were conducted in the MEDLINE, PubMed, and CINAHL databases. Limb length inequality and common classification criteria are defined and etiological factors are presented. Common methods of detecting limb length inequality include direct (tape measure methods), indirect (pelvic leveling), and radiological techniques. Interventions include shoe inserts or external shoe lift therapy for mild cases. Surgery may be appropriate in severe cases. Little agreement exists regarding the prevalence of limb length inequality, the degree of limb length inequality that is considered clinically significant, and the reliability and validity of assessment methods. Based on correlational studies, the relationship between limb length inequality and orthopaedic pathologies is questionable. Stronger support for the link between low back pain (LBP) and limb length inequality is provided by intervention studies. Methods involving palpation of pelvic landmarks with block correction have the most support for clinical assessment of limb length inequality. Standing radiographs are suggested when clinical assessment methods are unsatisfactory. Clinicians should exercise caution when undertaking intervention strategies for limb length inequality of less than 5 mm when limb length inequality has been identified with clinical techniques. Recommendations are provided regarding intervention strategies.

Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids

OBJECTIVE

To determine if intraarticular (i.a.) injection of triamcinolone hexacetonide (steroids) used early in the course of pauciarticular juvenile rheumatoid arthritis (pauci JRA) is associated with less leg length discrepancy (LLD) or thigh circumference discrepancy (TCD).

METHODS

Children with pauci JRA who had asymmetric lower-extremity arthritis diagnosed before age 7 years in Seattle, Washington (WA; n = 16) and in Chapel Hill and Durham, North Carolina (NC; n = 14) were retrospectively identified. WA children were given i.a. steroids within 2 months of diagnosis; the injections were repeated if synovitis recurred in the same joint or in a different joint. These children were compared with NC children who were not treated with i.a. steroids. Thigh circumference was measured at 10 cm above the patella, and leg length was measured from the anterior superior iliac spine to the mid-medial malleolus, by a single observer. LLD and TCD are reported as the percentage of difference between leg measurements in each subject.

RESULTS

The WA and NC subjects had comparable disease severity and duration of followup (in months). Twelve WA children had subsequent i.a. steroid injections (mean 3.25 injections per child over mean +/- SD 42 +/- 11 months). The WA subjects had significantly less LLD (P = 0.005, by Student's 2-sided t-test) and prescriptions for shoe lifts (P = 0.002, by Fisher's 2-sided exact test). There was not a significant difference in TCD between the 2 groups (P = 0.139, by Student's 2-sided t-test). Similar findings were obtained when the analysis was limited to children with monarticular knee arthritis.

CONCLUSION

Early and continued use of i.a. steroids may be associated with less LLD in young children with pauci JRA. This may indicate decreased duration of synovitis.