Page 4 P H Y S I O T H E R A P Y June, 1959 Management of the Short Leg By Mr. M . L U N Z , M .Ch. Orth. (L ’pool), F.R .C .S. (Eng.), Orthopaedic Surgeon. INEQUALITIES o f bone length are important causes of deformity in the human body. A short arm can be disguised adequately by the clothing and is o f no real significance. A discrepancy in leg length however produces a definite disability. Little is known about the factors which govern the rate o f growth or the symmetry o f the limbs and differences amounting to i" are found in the length o f the legs of otherwise normal individuals. These minor discrepancies are usually symptomless and require no special treatment. The more severe deficiencies and those that are known to be progressive are the subject o f this discussion. From a practical point o f view any discrepancy o f 1" requires treatment. COM M ON CAUSES OF INEQUALITY IN LIMB LENGTH 1. Anterior Poliomyelitis This disease is probably the commonest cause o f shortening although it rarely gives rise to severe degrees o f it. The behaviour o f growth in a paralytic limb- is unpredictable. Completely paralysed limbs may show little or no shortening whereas others with only partial paralysis may show 2" or more. Furthermore the shortening, may not be progressive, or if progressive, may not be uniformly so over a number o f years. 2. Tuberculous Arthritis o f the Hip. Most o f the severe grades o f shortening are due to this cause. U p to 8" o f shortening at maturity can occur. Here the cause for the shortening soon becomes evident. The epiphyses around the knee joint close prematurely. This complication, the mechanism o f which is not clearly under­ stood, was a real danger when Tuberculosis o f the hip was treated by prolonged immobilisation o f the affected limb on a splint or frame. It would appear that the advent o f the anti-biotics, and the shorter duration o f immobilisation now required in treatment, has significantly decreased this hazard. 3. Congenital Deformities These may cause inequality o f limb length in two ways. Congenital shortening o f the major long bones o f the limb or absence o f one o f these bones will give rise to a short limb, whereas arterio-venous communications o f congenital origin will give rise to a longer limb. In. the first type we find such conditions as congenital shortening or partial absence o f the femur, or congenital absence o f the tibia or fibula. In theory, these cases should be the most ideal for surgical treatment. The disability is due to the shortening per se, and normal function should result from successful lengthening o f the limb. Unfortunately it is precisely these cases where surgery does not succeed in gaining more than about J" o f increase. The hypertrophy o f the soft tissues in the limb may be the factor which offers resistance to lengthening. There are other causes o f inequality such as infective or traumatic destruction o f growing epiphyses. On the other hand, certain infective lesions close to growing epiphyses stimulate epiphyseal growth and therefore cause discrepancy by causing lengthening on the affected side. The commonest types however, fall into' one o f the three main groups mentioned above. ; METHODS AVAILABLE TO OVERCOME DISCREPANCY A. Alterations to Footwear. B. Surgery. A. Alterations to Footwear Shoes may be modified in a number o f ways to compensate for shortening. The particular method adopted will depend on the amount o f raise required, the sex o f the patient and the amount o f movement present in the associated joints. A raise o f Y is easily obtained by adding i" to one heel and shaving I" off the other heel. A raise o f V —2" can be provided by having a shoe made with a cork insole built inside. The appearance o f such a raised shoe should not be unduly resented by the patient. Any further raise above 2" should not be applied to shoes and boots should be provided and adapted for this purpose. Boots adequately built up with insoles can compensate for discrepancies up to 4i". Beyond this, it is necessary to provide an outside cork sole either alone, or in conjunction with the insole. It is possible to compensate up to 7"—8" with footwear but the appliance becomes cumbersome and particularly unsightly for a woman. B. Surgery The surgery o f limb length discrepancy may be carried out on the shorter or longer limb and it may be planned to take place during the growth period o f the individual or when growth has ceased. Surgery o f the Longer Limb During the growth period the rate o f growth in the longer limb may be permanently retarded by destroying one or more o f the epiphyseal plates. This will allow the short limb to catch up. This is the operation o f epiphyseodesis popularised by Phemister. There are two essentials for a successful result with this operation. The first is that the epiphyseal plate must be totally ablated in order to achieve complete bony fusion between the epiphysis and the meta-i physis. This ablation must be accurate and symmetrical! or else deformity will supervene. The second essential is that the anticipated amount o f growth both in the longer and the shorter limb has to.be accurately predicted to enable one to decide what number o f and at what age the epiphyseal plates should be ablated. The average annual growth increment at the lower femoral and upper tibial epiphyseal plates has been estimated by measurement in a large series o f normal children. Graphs and tables have been compiled from these figures and one can therefore refer to them to assess the correct time for operation in an individual case. There are objections to the operation o f epiphyseodesis and the two main ones are:— (a) that it is an operation on the normal limb and any failure or mishap would be catastrophic. (b) it leads to a loss in anticipated height at maturity. The site for this operation is usually the lower femur and. the upper tibia. The two epiphyseal areas at these levels give rise to almost J o f the' growth in length o f the lower extremity. The remaining i being provided for by the epiphysis at the upper end o f the femur and the lower end R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1959 P H Y S I O T H E R A P Y Page 5 o f the tibia. The operation o f stapling which is attributed to Haas and popularised by Blount attempts to retard growth temporarily. Here metallic staples are so placed that the limbs straddle the epiphyseal plates and thus tether the epiphysis to the metaphysis. They are left in situ until the discrepancy has been made up and can then be removed. Growth is then resumed at a more or less normal rate. Although attractive in principle this method is also rought with certain dangers and is not completely reliable. When the period o f grow th is over, or nearly so, shortening o f the shafts o f one or more o f the long bones—usually the femur may be undertaken. This is a simple relatively easy and accurate procedure, almost devoid o f complications. It has the drawback again o f reducing the height o f the patient and the hazard o f an operation on the normal limb. Surgery o f the Shorter Limb Theoretically the ideal solution to the problem o f inequality W j u- t(? st*mulate growth in the shorter limb. Attempts to do this have been made by trying to increase the blood supply in a limb as a whole. The operation o f sympathectomy jwas at one time enthusiastically undertaken for this purpose. J F . re.^ soon showed that the amount o f length gained was insignificant and the only improvement was in the skin circulation, in the cold blue limbs seen from time to time in poliomyelitis. Foreign bodies were introduced in the region o f the growing epiphyses around the knee-joint to cause local hyperaemia and therefore stimulation o f growth. These operations were, however, unsuccessful and a reliable method o f growth stimulation is yet to be found. Leg Lengthening During the last 20 years much attention has been given to the problern o f lengthening o f the short limb. Early attempts were attended by serious complications due largely to failure to control the alignment o f the divided bone. In the case o f the tibia the problem was solved by Abbot who devised the apparatus and described the mechanical principles which must be observed for the successful lengthen­ ing o f bone. In principle the bone is divided in a Z cut fashion so that there is some contact between the two ends throughout. The upper and lower fragments are transfixed with metal pins which are attached to a distraction apparatus. The limb and the apparatus is attached to a frame. By daily adjustment the transfixed fragments are slowly distracted until the maximum amount o f lengthening tolerated by the patient is obtained. The major danger is o f course due to over-distraction o f the blood-vessels and nerves in the limb, but with adequate care and attention to details and constant supervision up to 3" o f lengthening may be obtained in the tibia. This apparatus although easily adapted to the tibia cannot be applied to the .femur for anatomical reasons and in attempting to lengthen this bone the main difficulty is still that o f maintaining alignment. The upper fragment almost inevitably angulates forward resulting in a high incidence of malunion and non-union. Amputation This is probably the oldest o f all operations for a shortened limb. It is indicated in cases where severe shortening is associated with gross deformity or marked vascular dis­ turbance. Conclusion Certainly no surgical interference o f any description should be contemplated until the patient has been given a fair trial with suitable boot or shoe correction. There are no absolute indications for any o f the procedures described and apart from the varying degrees o f risk involved in all o f the procedures one must bear in mind that only rarely will successful lengthening improve function. p V a new approach to vasodilatation by the use of the potent new penetrative agent iNEWmm IB - ^ R u b i g u e n t FOR S P R A IN S , FIBROSITIS, ARTHRITIS, S T R A I N S A N D M U S C L E S P A S M Registered User o f Trade M ark and Distributors in South Africa: W YETH LABO RATO RIES (PTY.) LTD. 5 4 , STATION STREET, EAST LONDON. 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