Influence of leg length inequalities on pelvis and spine in patients with total hip arthroplasty

Background

Leg length inequalities (LLIs) are a common finding in patients with a total hip arthroplasty (THA). Therefore, we compared the effects of simulated LLIs in patients with total hip arthroplasty (THA) with a matched control group.

Research question

Do LLIs lead to different effects on the musculoskeletal apparatus of patients with a THA then in a control group?

Methods

In 99 patients with a THA the effects of simulated LLIs were compared to a matched control group of 101 subjects without a hip arthroplasty. First, we compared methods for LLI quantification (tape measurements, pelvic x- ray and rasterstereography). Second, the effects of simulated LLIs on the spine and pelvis were evaluated in both groups using surface topography. LLIs of 5, 10, 15, 20 and 30 mm were simulated on both sides with a simulation platform. The changes of pelvic position (pelvic obliquity & pelvic torsion) and the effects on spinal posture (surface rotation & lateral deviation) were measured and analysed using a surface topography system.

Results

Mean LLI measured with a tape was 0.9 mm (SD +/- 14.8). Mean pelvic obliquity measured on x-rays was 1.2 mm (SD +/- 11.6) and with surface topography 0.9 mm (SD +/- 7.9). Simulated LLIs resulted in significant changes of pelvic position and spinal posture in the patient and control group. Interestingly, our study showed that simulated LLIs lead to greater changes in pelvic position (p<0.05) in patients with a THA.

Significance

This is the first study to demonstrate that LLIs might have a greater impact on the pelvic position of THA patients than in native hips, which could indicate that LLIs do need to be compensated differently in patients with THA than in patients without a THA.

Transphyseal anterior cruciate ligament reconstruction in adolescents with substantial remaining growth causes temporary growth arrest resulting in subclinical leg-length discrepancy

The purpose of the present study was to investigate the characteristics of growth disturbances in patients with remaining growth after transphyseal anterior cruciate ligament (ACL) reconstruction who were confirmed to have no definite postoperative physeal abnormalities on magnetic resonance imaging (MRI).Forty adolescents (mean age 15.6 ± 1.0 years [range 12.2-16.8], mean follow-up 2.7 ± 0.7 years [range 2.0-5.5 years]), who underwent transphyseal ACL reconstruction and were confirmed to have no focal physeal disruptions on follow-up MRIs 6 to 12 months after the operation, were retrospectively evaluated. The patients were grouped according to the leg-length growth of the uninjured side, measured on scanograms, obtained before surgery, and at the final follow-up.Leg-length discrepancies (LLD) at the last follow-up were greater in patients with leg growth ≥4 cm than in those with leg growth <4 cm (5.3 ± 9.0 mm vs -0.3 ± 4.2 mm, P = .033); however, no significant difference was observed between subgroup patients with leg growth of 4 to 6 cm or ≥6 cm (5.6 ± 10.4 mm vs 4.8 ± 7.0 mm, P = .958). On multivariate analysis, leg growth was a significant predictive factor for the final LLD (P = .030).Adolescents with additional leg-length growth after transphyseal ACL reconstructions presented with greater LLDs (as shown in the <4 cm vs ≥4 cm groups), but they also presented a ceiling effect (as shown in the 4-6 cm vs ≥6 cm subgroups). Transphyseal ACL reconstructions appeared to cause temporary growth arrest/disturbances in patients with substantial remaining growth which then resumed resulting in clinically insignificant LLDs.

Modular femoral stems for revision total hip arthroplasty

BACKGROUND

Modular femoral stems are one option for revision THA surgeons and allow offset restoration, leg length discrepancy correction, and stability independent of distal stem fixation. The complexity of revision THA usually leads surgeons to use multiple revision hip designs to address these issues.

QUESTIONS/PURPOSES

We evaluated functional outcomes with a revision modular system and determined whether such a system achieved initial distal fixation, femoral offset restoration, leg length equalization, and hip stability.

METHODS

We prospectively followed 118 patients in whom a modular stem system was used for reconstruction of their failed index femoral stem. Sixty-nine hips were classified as Type I (classification of Paprosky et al.), 35 as Type II, 17 as Type III, and one as Type IV. Functional assessment was achieved using patient- and physician-administered outcome evaluations (SF-36, WOMAC, Lower Extremity Activity Scale, Harris hip score). Stem fixation, offset restoration, leg length discrepancy, and hip stability were evaluated radiographically. Complications were also recorded. Minimum followup was 2 years (average, 4 years; range, 2-7 years).

RESULTS

Average values on all functional outcome evaluations showed improvement at latest followup. Distal bone ingrowth fixation was obtained in 100% of the patients, offset was corrected in 66%, leg length discrepancy was corrected in 78%, and stability was achieved in 97%. No failures or fractures at the body to stem junction were seen at latest followup.

CONCLUSIONS

Modular femoral components achieved functional outcomes and were useful to address distal fixation, femoral offset restoration, leg length equalization, and hip stability when revising failed femoral components.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Leg-length discrepancy after transtrochanteric curved varus osteotomy for osteonecrosis of the femoral head

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25° (12° to 38°) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson’s correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy.

Crossed hemifacial hyperplasia: a diagnostic dilemma

Crossed hemifacial hyperplasia is a rare condition producing facial asymmetry and overgrowth of the extremities of the opposite side. Very few cases are reported in literature. A case of an 11-year-old female is presented here to supplement existing clinical knowledge with many of the reported clinical and orofacial findings. Emphasis is placed on diagnosis of the condition by thoughtful elimination and the necessity of a multi-disciplinary approach to its management.

Posteromedial approach to proximal tibia for corticotomy in callus distractions

Corticotomy of the tibia using Ilizarov's anterolateral approach is used routinely for callus distraction. This method is associated with impaired callus formation and delayed healing because of marginal soft tissue covering and blood supply to the proximal tibia. We presumed a newly designed posteromedial approach would result in less callus defects and improved healing. In this prospective, randomized study, 31 patients had callus distraction using an anterolateral approach or the newly designed posteromedial approach. Callus formation was assessed radiographically and histologically. Callus defects were classified using serial radiographs. Biopsy specimens were taken from high-grade defect (Grades 3-4) zones to examine the osteogenic potential. Radiographic evaluation showed 13 callus defects; 12 occurred after the anterolateral approach and only one occurred after the posteromedial method. Although low-grade defects (Grades 1-2) healed spontaneously, biopsy specimens taken from Grades 3-4 defects revealed no osteogenic potential and requiring operative revision. Because of low soft tissue covering and impaired blood supply to the anterior tibia during surgical exposure for corticotomy, less callus formation occurred after the anterolateral approach compared with the posteromedial approach. We recommend the less invasive posteromedial approach to reduce callus defects and impaired healing in callus distraction of the proximal tibia.

Vascular reconstruction using deep vein for limb length discrepancy in a child

Iatrogenic vascular injuries can result in claudication and limb length discrepancy in growing children. Traditional reconstruction has been performed with great saphenous vein as a conduit. We report the case of a 7-year-old boy with a symptomatic limb length discrepancy and vascular reconstruction using femoropopliteal vein. The use of deep vein as an autogenous conduit may facilitate reconstruction of iliofemoral arteries in preadolescent children, providing an excellent size match and an efficacious means of restoring normal blood flow.

Stapling of knees with valgus deformity in children with juvenile chronic arthritis

OBJECTIVE

Leg length discrepancy and excessive knee valgus are potential complications of juvenile chronic arthritis of the knee. The aim of the present study was to evaluate retrospectively the safety and efficacy of temporary stapling of the knee epiphyses in management of valgus deformities of the knee in children with JCA.

METHODS

Medical data of the patients with temporary epiphyseodesis due to knee valgus deformity (KVD) were studied. 177 knees in 112 patients were found with sufficient data for evaluation. Patient documents and radiographs of these patients were evaluated.

RESULTS

Mean age at the time of operation was 8 years (range: 2 - 17) in 19 males and 93 females. The patients are predominantly affected by aggressive polyarticular disease. Preoperative mean valgus angle was 11 degrees (IQR: 9, 14) and at staple removal 4 degrees (IQR: 2, 5). In 120 of 177 knees (68% [95% CI: 61 - 74], p < 0.001) the physiological angle (3-8 degrees) was reached. Median time of stapling was 10 months (IQR: 8, 13). Five reversible and one irreversible (3% [95% CI: 2 to 7]) major complications were documented among the 177 stapled knees.

CONCLUSION

Temporary epiphyseal stapling enables flexible correction of KVD in children with JCA. Low complication rate encourages the use of the method. Prompt follow-up is, however, important in avoing excess over-correction to varus.

Musculoskeletal manifestations of Russell-Silver syndrome

The musculoskeletal manifestations of Russell-Silver syndrome were studied in 25 patients. The most common manifestations were short stature (25 patients), limb-length discrepancy (23 patients), clinodactyly (19 patients) metacarpal bone and phalangeal abnormalities (13 patients), scoliosis (9 patients), foot syndactylism (5 patients), and developmental dysplasia of the hips (3 patients). Five patients underwent lower extremity limb-lengthening procedures for discrepancies greater than 3 cm and three patients had successful pelvic and/or femoral osteotomies for hip dysplasia. All 18 patients studied had retardation of bone age, which peaked at age 7 years.

[Management of fibular hemimelia with the Ilizarov circular external fixator]

OBJECTIVES

We evaluated the results of treatment with the Ilizarov circular external fixator for limb length inequality and deformities in patients with type IA, IB, and type II fibular hemimelia.

METHODS

Tibial corticotomy and distraction osteogenesis with the Ilizarov technique were performed in five male patients (mean age 11.4 years; range 4 to 20 years). According to the classification of Achterman and Kalamchi, fibular hemimelia was type IA, IB, and II in three patients, one patient, and one patient, respectively. Involvement was on the right in three patients, and on the left in two patients. Two patients had equinus and one patient had valgus deformities. No instability existed in the ankle and knee joints. The mean leg discrepancy was 8.7 cm (range 3 to 16.5 cm), and the mean lengthening index was 1.6 cm/month (range 1.4 to 2 cm). The mean follow-up was 33 months (range 15 to 68 months).

RESULTS

On final examinations, full range of motion of the knee was obtained. A plantigrade foot was achieved in three feet, while two sustained an equinus deformity of 17 and 15 degrees, respectively. Pin tract infections were observed in four patients, all of which were treated with oral antibiotics and dressing. During distraction, three patients had pain. Two patients had a limited range of motion of the ankle joint, without instability or subluxation of the ankle and knee joints. These joint problems were successfully dealt with by physical exercises.

CONCLUSION

The Ilizarov technique is a convenient method in the correction of angular and rotational deformities while enabling distraction in type I and type II fibular hemimelia.

[Van Nes rotationplasty in two patients with congenital femoral deficiency]

Congenital femoral deficiencies have a wide spectrum ranging from simple hypoplasia to complete femoral aplasia. They are often associated with congenital shortening of the tibia and fibular hemimelia. This anomaly has no known genetic transmission. There are two main treatment modalities for congenital femoral deficiency: prosthetic replacement surgery (Syme amputation or Van Nes rotationplasty followed by prosthetic fitting) and lengthening reconstruction surgery. In this report, we presented two patients (male, 26 years; girl, 7 years) with congenital femoral deficiency treated with Van Nes rotationplasty. In both cases, the treatment took 1.5 months, after which the patients were mobilized with prosthesis. No complications were encountered within a follow-up period of five years and 1.5 years, respectively. Rotationplasty enables an improved functional gait in patients with a very short femoral segment or Paley type 3 femoral deficiency.

Pelvic bone asymmetry in 323 study participants receiving abdominal CT scans

STUDY DESIGN

Retrospective review of all CT scans of pelvis and abdomen performed at our institution in October and November 2000.

OBJECTIVE

To determine the prevalence and extent of radiographic pelvic asymmetry in a population of patients not preselected for having low back pain.

SUMMARY OF BACKGROUND DATA

Pelvic asymmetry refers to asymmetric positioning of landmarks on the two sides of the pelvis and may have a structural or functional etiology. Pelvic asymmetry can be associated with the presence of true leg length discrepancy, lead to false diagnosis or inaccurate measurement of leg length discrepancy, or itself be independently associated with back pain. Although the prevalence of pelvic asymmetry has been reported in patients with back pain to be 24-91%, its prevalence in the general population is not known.

METHODS

A total of 323 consecutive CT scans of the pelvis/abdomen were assessed for pelvic asymmetry by one of three examiners. Pelvic asymmetry was defined as an unequal distance from the iliac crests to the acetabuli bilaterally, measured on the anteroposterior scout view of the CT scan. Measurements made on 30 randomly selected scans by the three examiners were used to assess interrater reliability of the measurement method.

RESULTS

Pelvic asymmetry ranged in magnitude from -11 mm to 7 mm [right pelvis (mm) - left pelvis (mm)]. Pelvic asymmetry was >5 mm in 17 of 323 (5.3%) and >10 mm in 2 of 323 (0.6%) of the subjects; 172 of 323 (53.3%) had a smaller right hemipelvis (mean asymmetry = -3.0 mm). A total of 95 of 323 (29.4%) had a smaller left hemipelvis (mean asymmetry = 2.1 mm). The intraclass correlation coefficient [ICC(2,1)] between the three observers was high (0.91).

CONCLUSION

Pelvic asymmetry of >5 mm was uncommon, with a prevalence of approximately 5% in the population studied. CT scanography was found to be a practical and reliable method for the assessment of suspected pelvic asymmetry.

[Dynamics of echomorphometric human crural skin characteristics during dosed stretching]

The dynamics of echo-morphometric parameters of crural skin was studied in patients with congenital shortening of lower extremity in the process of its operative elongation. It is demonstrated that dosed stretch results in increased skin thickness. After the completion of distraction, the skin thickness exceed preoperation levels by 48.7% (in patients aged 5-8 years), 20.9% (in patients aged 10-14 years) and 26.7% (in adults). Skin acoustic density after distraction termination reached the preoperation level in children and adolescents, while it was increased in adults.

Neonatal ablation of the nigrostriatal dopamine pathway does not influence limb development in rats

Hemiparkinson-hemiatrophy syndrome (HP-HA) is associated with skeletal hemiatrophy and the later development of parkinsonism. It is generally assumed that this phenotype is due to the combination of dysfunction of the basal ganglia (e.g., substantia nigra compacta and/or other related structures), causing parkinsonism, and of other areas (e.g., cerebral cortex), causing hemiatrophy. The occurrence of asymmetry of limb size in a patient with very asymmetric involvement of dopa-responsive dystonia encouraged Greene et al. (2000, Mov. Disord. 15: 537-541) to propose that lifelong deficits in nigrostriatal dopamine could account for limb asymmetry in HP-HA. The purpose of this study was to determine whether skeletal hemiatrophy could be produced in rats by unilateral, neonatal ablation of the nigrostriatal dopamine pathway. Infusion of 6-hydroxydopamine into the striatum of rat neonates resulted in loss of dopamine neurons in the ipsilateral substantia nigra, reduced striatal dopamine levels, and stimulant-induced motor asymmetry. Saline infusions neither altered the number of dopamine neurons nor produced behavioral changes. Both groups incurred discrete lesions of the ipsilateral motor cortex surrounding the infusion site and atrophy of the corresponding cerebral peduncle. Cortical, but not nigrostriatal, lesions were associated with significant atrophy of ipsilateral femora, humeri, and innominate bones, as assessed radiographically. Skeletal hemiatrophy was not observed in naive animals or in experimental animals that did not exhibit corticospinal abnormalities. The results of this study indicate that early skeletal development in rats is not affected by loss of nigrostriatal dopamine per se, but is markedly attenuated by corticospinal lesions sustained during the neonatal period.

[Slipped capital femoral epiphysis and the "healthy" opposite hip]

The gold standard in the therapy of SCFE is the bilateral procedure in Central Europe. Several statistics demonstrate more than 30% of bilateral slippage as an average. Complications such as accidental pin perforation have become rare since the introduction of large cannulated screws. The advantage of screws as an implant is the easier removal of the device after termination of growth. Exceptionally, only the involved site may be operated on when cessation of growth is to be expected immediately. Because the disease takes place in the growing area of the femur, leg length differences up to 2 cm are not unusual and cannot always be avoided.

Growth hormone treatment does not alter lower limb asymmetry in children with Russell-Silver syndrome

BACKGROUND

Growth hormone (GH) treatment has been proven to have a beneficial effect on growth in children with Russell-Silver syndrome (RSS).

METHODS

We describe 7 prepubertal children with RSS and lower limb asymmetry treated with GH for 3 years.

RESULTS

There was a significant increase in height without any significant change in the asymmetry.

CONCLUSIONS

We conclude that the rapid growth acceleration to GH treatment does not alter the lower limb asymmetry in children with RSS.

[Osteoma cutis, a case report from the orthopedic viewpoint]

Osteoma cutis is a benign cutaneous disease which causes a primary heterotopic ossification of the skin. Corresponding to the appearance it is possible to distinguish four modifications. The enlargement of osteoma cutis can disturb the function of joints and statics. The etiology of the disease is unknown. Hamartoma or metaplasia is subject of discussion. It is important to mark off osteoma cutis from pseudohypoparathyreoidism (Albright-syndrome++).

Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle

We studied 101 patients who were operated on at Oulu University Hospital for ruptured Achilles tendon from 1987 to 1992 (inclusive), and 87 healthy control patients from among Army conscripts. The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. An underpronating alignment of the ankle and foot (based on beta45 measurement of the angle < or = 4 degrees) was found in 21% of patients and 5% of controls (P < 0.001). A combination of high longitudinal arch and underpronating alignment of the ankle was seen in 10% of patients and 1% of controls (P < 0.001). About 37% of the patients' feet and 29% of feet in controls were classified as having a high arch (P = 0.001). ILL or hyperpronation of the ankle seem to not be predisposing factors for ruptures of the Achilles tendon. High longitudinal arches were somewhat overrepresented, being associated with less pronation of the ankle and less varus in the forefoot than was seen in controls.

Brachytelephalangic chondrodysplasia punctata with distinctive phenotype and normal karyotype

We present two sibs with a distinctive phenotype and with stippled calcifications of the tarsal bones and sacro-coccygeal spine. They represent an apparently "new" form of chondrodysplasia punctata.

The effect of limb-length discrepancy on gait

We evaluated the gait of thirty-five neurologically normal children who had a limb-length discrepancy of the lower extremities that ranged from 0.8 to 15.8 per cent of the length of the long extremity (0.6 to 11.1 centimeters). The twenty-two boys and thirteen girls had an average age of thirteen years (range, eight to seventeen years). No patient had a substantial angular or rotational deformity of the lower extremities. We found no correlation between the actual discrepancy or the per cent discrepancy and any of the dependent kinematic or kinetic variables, including pelvic obliquity. Discrepancies of less than 3 per cent of the length of the long extremity were not associated with compensatory strategies. When a discrepancy was 5.5 per cent or more, more mechanical work was performed by the long extremity and there was a greater vertical displacement of the center of body mass. Clinically, this degree of discrepancy was manifested by the use of toe-walking as a compensatory strategy. Children who had less of a discrepancy were able to use a combination of compensatory strategies to normalize the mechanical work performed by the lower extremities.

Wound healing in orthopaedic procedures for Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome is a triad of cutaneous hemangiomas, varicose veins, and hypertrophy of soft tissue and bone; when combined with arteriovenous fistulas, the syndrome is known as Klippel-Trenaunay-Weber syndrome. Orthopaedic surgical management of localized limb-length discrepancy or hypertrophy in these conditions is frequently indicated, especially in the lower limb. Forty orthopaedic procedures in 21 patients were retrospectively reviewed. Nine (22.5%) wound complications were identified in this study group. All the complications were associated with transverse amputations. All required significant further treatment and extension of hospital stay. Wound complications should be anticipated in patients with Klippel-Trenaunay syndrome having orthopaedic surgical procedures, especially terminal amputations.

Narrowing of the joint space of the hip after traumatic shortening of the femur

Femoral lengthening has been associated with narrowing of the joint space at the hip. We have studied the joint space before lengthening in 20 patients with a short femur due to a femoral-shaft fracture (15) or distal femoral epiphyseal injury (5). Their mean age at injury was 16 years (3 to 27) and the mean shortening was 5.4 cm (1.1 to 14). We found that the hip joint space of the shortened femur was significantly narrower (p < 0.001) than that on the normal side, with a mean narrowing ratio of 15.5% (-5 to +43). The narrowing ratio was directly related to the period spent non-weight-bearing (p < 0.001), but not to the amount of femoral shortening. We have shown that the joint space of the hip in patients with post-traumatic femoral shortening was narrowed even before femoral lengthening had been started.

Myofascial pain syndrome of the peroneus longus: biomechanical approach

OBJECTIVE

The aim of the study was to investigate the role played by anatomical (lower limb length discrepancy) and biomechanical (alterations in the dynamics of movement) factors in the pathophysiology of myofascial pain syndrome (MPS) of the peroneus longus.

DESIGN

Patients affected with MPS of the peroneus longus of one side were submitted to either correction of their lower limb discrepancy by heel lift (6 patients) or normalization of altered biomechanical parameters during movement, as measured via ground-foot reaction analysis (g-f) by dynamic insoles (6 patients) for 60 days. At days 7, 15, 30, and 60, the effect of treatment was verified on painful symptoms [VAS scale, presence of the active trigger point (TrP) in the muscle] and on g-f parameters [peaks of vertical force (F1 and F3 of Fz) and of lateral shear force (Fx)].

RESULTS

Treatment with heel lift produced a moderate, significant reduction of the spontaneous pain and of the abnormal Fx peak in the affected leg after 7 to 14 days with no further improvement afterward. Treatment with dynamic insoles caused a marked, significant reduction of the pain at 7 days, with complete resolution of the painful symptoms at 30 days and concomitant disappearance of the active TrP in the muscle. It also produced a significant and progressive reduction of the abnormal Fx peak in the affected leg starting at the 7th day and continuing until the 60th day.

CONCLUSION

Both anatomical and biomechanical alterations of the dynamics of movement play a role in the painful symptoms of MPS of the peroneus longus, but the biomechanical factor is by far the more prominent.

[Intraoperative assessment of leg length in alloplastic hip joint replacement]

A new measuring device has been developed at the Orthopedic Clinic of the University of Tübingen. Its task is to ensure that the right length of leg is selected intraoperatively. The method of measurement can be used in all approaches for alloplastic hip replacement when the patient is in the supine position. Measurement is quick, non-invasive, and can be carried out in a direct comparison to the contralateral leg, using measuring points at the iliac crest and the upper edge of the patella. In a prospective randomized study we were able to demonstrate on 53 patients that the use of this newly-developed measuring device improves the accuracy of the length of the operated leg as compared to the contralateral leg, so that the difference is only +/- 0.5 cm (post-operative difference in length of leg without use of the measuring device 1.1 cm on average, with the measuring device 0.5 cm; p < 0.05).

Palpable unilateral sacral prominence as a clinical sign of lower limb anisomelia: a pilot study

OBJECTIVE

To examine the role of oblique-axis sacral torsion in the presence of true or apparent short leg.

DESIGN

Prospective blind trial of eighteen subjects.

SETTING

A suburban chiropractic practice, a hospital and a university campus.

SUBJECTS

Of 33 subjects selected, 27 completed the study, 8 exhibited elimination criteria, and 1 X-ray was nondiagnostic.

MAIN RESULTS

3 x 3 contingency table showed the presence of unilateral sacral prominence as statistically significant (p > .001) in subjects with LLI. The incidence of unilateral sacral prominence on the short leg side was also significant (p > .05). Weighted kappa confirmed both (alpha > .001).

CONCLUSIONS

Oblique-axis sacral torsion may play a role in intrapelvic adaptation to anisomelia of the lower limb; further examination of this prospect is warranted.

Persistent sciatic artery in association with varicosities and limb length discrepancy: an unrecognized entity?

The persistence of the sciatic artery is an unusual occurrence, with an angiographically demonstrated incidence of 0.06%. There have been 71 cases previously reported. We report an additional case in a 14-year-old boy who presented with a chief complaint of unsightly varices. The involved right limb was notably shorter than the uninvolved left lower extremity. Work-up included physical examination, duplex studies, venography, and angiography. Our patient was found to have a patent deep venous anatomy with valvular incompetency associated with complete persistence of the sciatic artery and a foreshortened right leg. He has done well with conservative treatment. The persistence of a sciatic artery has occasionally been associated with other anomalies including Mullerian and left renal agenesis, A-V fistula formation, hypertrophy or hypotrophy, multiple hemangiomata, neurofibromatosis, or anomalies of leg arteries. The literature describes three previous case reports in which patients presented with gross varicosities and were incidentally found to have persistent sciatic arteries as well as limb length discrepancies. Our patient is a fourth example of this syndrome. This pattern of physical attributes has not been previously described as a distinct entity. The association of venous incompetency, limb discrepancies, and persistence of the sciatic artery may be an incidental finding or may represent a related embryologic event. This relationship merits consideration in a young patient presenting with severe venous varicosities.

Computer-assisted assembly and correction simulation for complex axis deviations using the Ilizarov fixator

In axis correction with the Ilizarov ring fixator, the correction results are often insufficient or there are unexpected translation effects, which can be causally attributed to wrong preoperative planning or inaccurate assembly. To avoid such results, computerised simulation was developed. Via digitalisation of the bone outlines traced from X-radiographs with an additional scale, preoperative correction planning can be performed, simulated with normal software. This can be used while constructing the apparatus and positioning the joints. In addition, the translation effect of the bone fragments can be simulated by arbitrarily choosing the pivot of the correction. In transferring the X-radiograph true to scale, one can compare the ring planes before and after correction. It is possible to estimate the necessary distraction as well as compression and thus the postoperative distraction mode. Using computerised planning, the apparatus construction can be optimised and complications caused by misplanning avoided. Not only the inexperienced user can benefit from this aid.

Predictability of sacral base levelness based on iliac crest measurements

A level sacral base plane is necessary to allow normalization of complex lumbosacral mechanics. Palpatory examinations are often used to evaluate for leg length discrepancy and pelvic obliquity despite improved accuracy and consistency of radiographic techniques. Treatment based on palpatory examinations suppose a direct and consistent relationship between the pelvic bones (innominates) and the sacral base. To evaluate the relationship between iliac crest levelness and sacral base levelness, a radiographic postural survey in the upright, weight-bearing position was performed on 358 men and women thought to have pelvic obliquity. Of these subjects, 293 demonstrated unlevel iliac crest heights or sacral base > or = 3/16 inch (4.76 mm), with iliac crest heights accurately predicting sacral base position 62% of the time. At > or = 3/8 inch (9.53 mm), 68% of the cases were accurately predicted. When the criterion for unlevelness was increased to > or = 1/2 inch (12.70 mm), the predictive accuracy improved to 83%. Radiographic findings in this study demonstrate a significant difference between iliac crest heights and sacral base position. In cases of mild to moderate short leg syndromes, the iliac crest height is an unreliable predictor of the direction or degree of sacral base levelness.

Evaluation of physeal behavior in response to epiphyseodesis with the use of serial magnetic resonance imaging

The stages in the closure of the growth plate after percutaneous epiphyseodesis were studied in fourteen patients (eight girls and six boys) with coronal T1-weighted spin-echo images and coronal field-echo images of the knee. A total of thirty-three magnetic-resonance imaging studies of the knee were made the first week, the fourth month, the eighth month, or one year after the epiphyseodesis. A mature bridge of bone was seen at the operative sites approximately eight months after the operation. In the central undisturbed area between the operative sites, there was a progressive decrease in the width of the physeal cartilage that remained visible eight months after the operation. Growth recovery lines were not seen postoperatively in any patient, and the physis closed in all of the patients. The physis of the adjacent untreated bone served as a control bone and showed neither a change in width nor any growth recovery lines. Magnetic resonance-imaging studies provide excellent visualization of the anatomical changes that lead to closure of the physis after an epiphyseodesis, and we believe that these studies provide a method of assessment of the physis after an injury.

Double oblique diaphyseal osteotomy. A new technique for lengthening deformed and short lower limbs

We treated 25 patients with severely deformed and shortened lower limbs by double oblique diaphyseal osteotomy of the short deformed bone, followed by balanced skeletal traction to correct the alignment and increase the length of the limb. The technique is simple and inexpensive and does not require special equipment. It has the advantage of allowing rapid lengthening and secure healing as the overlap allows end-to-end union with no bone gap. The lengthening achieved ranged from 6 to 16 cm. No serious complications were encountered.

Triple innominate osteotomy for hip stabilisation and transiliac leg lengthening after poliomyelitis

We reviewed our experience with a modified triple innominate osteotomy for hip instability and limb shortening due to poliomyelitis in 62 adolescent and adult patients, treated from 1973 to 1990. Their ages at surgery ranged from 12 years to 35 years (average 22.3). At a mean follow-up of 4 years (2 to 18) 59 of the patients (95.2%) had substantial improvement in hip stability, and all but one had radiological improvement as determined by the acetabular angle, centre-edge angle and acetabulum-head quotient. In 59 cases in which transiliac limb lengthening was attempted, the mean gain was 1.7 cm (0.6 to 3.0). When the abductor muscles had been partially paralysed, the operation produced an appreciable increase in power in 12 of the 39 hips examined.

Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding

Five skeletally immature patients developed premature closure of the greater trochanteric physis consequent to placement of an intramedullary rod for primary treatment of a femoral diaphyseal fracture. Each patient developed increased femoral neck valgus as compared with the contralateral hip. To date, however, none of these patients has had any functional disability, although one has developed mild radiographic subluxation. In addition, anatomic specimens demonstrated the likelihood of traversing a portion of the greater trochanteric physis. Other methods of fracture treatment, either operative or nonoperative, should be considered in skeletally immature patients who have not entered the final phase of skeletal maturation characterized by subchondral "sclerosis" along the greater trochanteric physis.

Linear scleroderma with severe leg deformity

Linear scleroderma is an unusual form of localised scleroderma, mainly affecting the legs and occurring primarily in children. Sometimes the linear lesions may extend to involve the underlying muscles and bones, with severe disturbances in growth and possibly flexion deformities of the legs. In this study, two cases suffering from linear scleroderma of the legs are presented.

[Observer agreement in the measurement of leg length]

The lower limb length measurement is an important element for the diagnosis of mechanical or structural lumbar pain. Also it has been used for referral pain associated with hip or knee osteoarthritis or the groin and suprapubic areas. The aims of the present study were: 1) to measure the intra and inter observers variation; 2) to measure the intra-method variation using two different techniques for lower limb length measurement, one called the "apparent measure" (9) and comparing both with the radiological measurement technique. Two medical doctors, training on the techniques for lower limb measurement, performed the measurements. The exclusion criteria were flexion deformity of the hip or an overweight greater than 20% over the mean weight expected according to age and sex. A correlation coefficient and its 95% confidence interval (CI) were estimated, one tail test (Ho: r = 0.75). Seventeen patients fulfilled the inclusion criteria, 15 females and two males. The mean age was 35.8 years +/- 13.0 (SD). The correlation coefficient for the inter-observers variation using the "apparent measure" was 0.99 (CI = 0.985) and for the difference between legs it was 0.88 (CI = 0.10). The inter-observers variation for lower limb length measurement using the technique of "real measure" showed a correlation coefficient of 0.77 (CI = 0.95) and for the difference in length between legs it was 0.99 (CI = 0.85). The intra-observer correlation coefficient was 0.95 (CI = 0.85). The correlation coefficient for the inter-observer using the X-ray pictures was 0.98 (CI = 0.92).(ABSTRACT TRUNCATED AT 250 WORDS)

Limb length discrepancies

Examining for a possible limb length discrepancy is an important part of the podiatric biomechanical examination. The authors present a review of the literature pertaining to the definition of and examination for a limb length discrepancy. They present a typical rationale for lift therapy in the treatment of this pathology.

Calculating rate and duration of distraction for deformity correction with the Ilizarov technique

Longitudinal bone lengthening with distraction histogenesis is typically carried out at a rate of 1 mm per day. Angular corrections require an adjustment of the rate of distraction according to the geometry of the external fixator relative to the bone or soft tissue being lengthened. Modeling the deformity correction construct using simple geometric principles allows calculation of both the rate of correction and the expected duration of distraction.

[Biochemical and anatomic changes in the muscles after leg bone lengthening by the Ilizarov method]

In process of crus lengthening, following the method, given by Ilizarov G. A., with 22 adult patients have been studied the peculiarities of metabolic processes of muscle tissue of the lengthened segment as well as the muscle tissue structural changes. As the tests were used; determination of lactate dehydrogenase content and its isoenzymatic spectrum in the blood serum, the residual products of lactic and pyruvic acids glycolysis, relating to the higher indications of the internal medium of an organism; carboxylase activity detection. Energy provision of an organism was estimated according to the ATP content; anatomical state of muscles of the lengthened extremity segment and muscle tissue structure were estimated by means of contrast myography. Dynamics of biochemical indexes suggests that the sparing character of an operation, patient mobility from the first days, preservation of locomotive and supporting function contribute to prevention of metabolic disease and ensure earlier transformation of catabolic reaction to anabolic one. Carboxylase and lactate-dehydrogenase activity increase indicates the biochemical adaptation of an organism. Metabolic changes well correlate with the detected structural changes in the lengthened crus muscles.

Another CHILD syndrome with xanthomatous pattern

We report on a patient with verruciform xanthoma lesions in an epithelial nevus and developmental anomalies since birth that may be classified as CHILD syndrome (congenital hemidysplasia with ichthyosiform erythroderma and limb defects). Histological analyses of the lesion revealed verrucous features with acanthosis, hyperkeratosis, parakeratosis and the typical infiltrate of xanthomatous cells in dermal papillae. To our knowledge only 5 cases of verruciform xanthoma on epidermal nevus have been reported to date. In our view, the present case of CHILD syndrome is the first reported in which xanthomatous transformation has been revealed in biopsies taken when the girl was a baby.

Leg length equalization during total hip replacement

A method of equalization of leg lengths during total hip replacement surgery was developed which utilizes the concept of equalizing the vertical dimensions of the resected femoral head and neck segment and the remaining hip joint cartilage space, which are removed during the procedure, with the vertical dimensions of the femoral and acetabular prostheses, which are implanted into that void. This was accomplished by determining the dimensions of the prostheses from careful preoperative templating technique and by using a simple arithmetic formula to determine the level of the femoral neck osteotomy. The level of the osteotomy was made by a measurement from the top of the dislocated head of the femur to the medial femoral neck calcar. The radiologic postoperative leg length differences of a consecutive series of 84 patients undergoing primary total hip replacement using this method were determined. The average discrepancy was 2.8 mm. Seventy-five patients (89%) were found to have a postoperative leg length discrepancy of 6 mm (1/4 inch) or less. Six patients (7%) had a discrepancy of 7 to 13 mm, and only three patients (4%) had more than 13 mm (1/2 inch) leg length difference. Using this technique only two patients (2.5%) with unilateral hip replacements had leg lengthening of more than 6 mm.

Lower limb asymmetry and patellofemoral joint incongruence in the etiology of knee exertion injuries in athletes

The association between different knee exertion injuries and lower limb malalignments was studied in 121 male athletes with knee exertion injuries and in 20 male athletes without knee symptoms. The associations between different malalignments was also analyzed. Leg length inequality (LLI), knee valgus, and different indexes of patellofemoral joint congruence were measured using radiological methods. Male athletes with patellar apicitis (n = 59) had significantly more LLI (P less than 0.001) and patella alta (P less than 0.05) than athletes without knee symptoms. The knee valgus was of the same numerical value in the shorter and longer leg sides in subjects with LLI of at least 5 mm (n = 58). A positive correlation was found between lateral patellar displacement (LPD) and patella alta (LT/LP) (P less than 0.001). Negative correlations were found between the sulcus angle (SA) and the lateral patello-femoral angle (LPA) (P less than 0.001) as well as between the LPD and the LPA (P less than 0.001).

[Radiologic findings in idiopathic scoliosis. Etiopathogenetic interpretation]

Following radiological investigations of the spine and pelvis, carried out in the standing position on 5000 young and adult subjects, the author reports a series of radiological features from which it appears clear that the inequality in length of lower extremities is the primary cause of that complex mechanism which is responsible of apparently idiopathic scoliosis.

Genesis of the ball-and-socket ankle

Ball-and-socket ankle is a rare deformity associated with such pre-existing conditions as congenital shortening of the lower limb, coalition of tarsal bones, absent digital rays and aplasia or hypoplasia of the fibula. We have observed seven patients with this deformity for an average of six years from initial examination at 20 days to 3.5 years. Arthrography showed that the configuration of the ankle was apparently normal in patients under 10 months of age and that a ball-and-socket joint develops by four to five years of age, possibly in compensation for the loss of inversion and eversion caused by tarsal coalition. Ball-and-socket joint is therefore probably not congenital, but is an acquired deformity secondary to various pre-existing congenital conditions.