A concise overview of the orthopaedic management of limb length discrepancy and bone gaps

1. Management of LLD and
Bone gaps
Dr Bassey, A. E.
Supervised by Dr T. Sough

2. Limb Length Discrepancy
• Introduction
• Aetiology
• Classification
• Problems
• Assessment
• Treatment
• Complications
• Current trends

3. Introduction
• Limb length discrepancy refers to any noticeable inequality in limb
length
• Associated with cosmetic and functional problems which significantly
limit quality of life
• Proper management is necessary for best outcomes

4. Aetiology
• Congenital
- PFFD
- Tibial hemimelia
• Acquired
- malunited fracture
- physeal injuries
- Paralytic dxs – Polio, CP

5. Classification
• Congenital v Acquired
• Static v Progressive

6. Problems
• Cosmetic
• Functional – increased energy expenditure
• Scoliosis/back pain
• Hip/Knee/Ankle arthrosis

7. Assessment
• History
• Congenital/acquired
• Anatomical/functional
• Age of presentation
• Associated deformities
• Examination
• Real/Apparent length
• Spine exam

8. Assessment
• Imaging
• Orthoradiograph
• CT Scanogram
• Prediction of LLD at maturity

9. Treatment
• < or = 2cm LLD do not need Rx except symptomatic
• Techniques
• Shoe raise/lift
• Shorten long leg
• Slow growth of long leg
• Lengthen short leg
• Amputation and prosthesis

10. Treatment

11. Shoe raise/lift
• LLD <5cm
• Unsafe for LLD >5cm

12. Shorten long leg
• Acute shortening
• Deformity < or =7cm

13. Slow growth of long leg
• Epiphyseodysis
• Timing and technique are crucial to success

14. Lengthen short leg
• Distraction osteogenesis

15. Amputation and prosthesis
• A viable option in patients with LLD >15cm

16. Complications
• Incomplete arrest, Angular deformities
• Regenerate fracture, docking site nonunion

17. Current trends
• PRECICE System

18. Management of Bone gaps
• Introduction
• Aetiology
• Assessment
• Treatment
• Complications
• Current trends

19. Introduction
• Bone gaps refer to any defect in length or circumference of bone
• Critical bone gap
• Causes significant disability. Care is often complex and costly
• Treatment methods are prone to complications. Therefore, high
degrees of knowledge, decision-making and technical skills are
required

20. Aetiology
• Congenital – CPT, diaphyseal dysplasia
• Acquired – Trauma, Infection, nonunion, post tumour excision

21. Assessment
• History
• Hx of Aetiology
• Duration
• Previous Rx
• Tobacco use
• Medical comorbities e.g. DM
• Examination
• General condition (esp nutritional state)
• Soft tissue envelope
• Perfusion
• Any LLD?
• Any deformity?

22. Investigations
• Xrays - gap size, surrounding bone, aetiology.
• FBC, ESR, genotype, FBS, U&E, Swab m/c/s.
• Doppler USS.

23. Treatment
• Multidisciplinary approach, highly-individualized
• Adequate counselling with proper management of expectations
• Patient optimization
• Nutrition
• Stop tobacco
• Correct Hb conc
• Correct glycaemia
• Consider metabolic or endocrine derangements

24. Treatment
• Treatment of soft tissue defects
• Utmost importance
• Plastic surgeon involvement from outset
• Simplest technique to achieve cover should be used
• Outcomes less predictable than bone recon

25. Treatment of bone defect
Management method Size of
defect
Advantages Disadvantages
Autologous graft <5cm 1. Single stage
2. No dx/no rejection
3. Has 3 elements of graft
1. Donor site morbidity
2. Limited quantity
Induced membrane technique 5-24cm 1. recon time independent of defect length
2. Low cost
1. Donor site morbidity
2. 2-stage
3. Limited ‘assistance’ by allograft
Distraction osteogenesis 5-10cm 1. Can be used with poor soft tissue
2. Multiple osteotomie reduce recon time
1. High rate of complications
2. Frame/implants are expensive
Acute shortening 1-3cm 1. Simple, fast
2. Allow early soft tissue closure
3. Low cost
1. Limited defect length
Vascularised fib graft 10-20cm 1. Shorter recon time
2. Lowcost
1. Requires microvascular
2. Donor site morbidity
Amputation 1. Short Rx time than salvage
2. Some studies show equivalent outcomes
1. Permanent limb loss
2. Lifetime prosthetic cost

28. Complications
• Complications of management methods

29. Current trends
• VFG left behind
• Introduction of graft substitutes with osteoprogenitor cells and
osteoinductive cytokines

30. Conclusion
• LLD and Bone gaps are still common problems in our environment,
and will likely remain so for as long as poverty, ignorance and
traditional bone setters remain
• There is some overlap f techniques in their management
• Best outcomes are achieved when such cases are managed by
surgeons specializing in these techniques

31. References