Leg-length discrepancy and Its management 성균관의대 삼성서울병원 심종섭
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1 and Its management 성균관의대 삼성서울병원 심종섭
2 Etiology of Undergrowth Congenital limb deficiency : congenital femoral deficiency, congenital fibular deficiency, tibial hemimelia Asymmetrical neurological disorders : hemiplegic CP, poliomyelitis, hemimyelomeningocele Traumatic causes: malunion, growth plate arrest Hemiatrophy: Idiopathic, Russel-Silver syndrome Other causes: infection, tumor, post-irradiation, Blount s disease, LCPD, unilateral clubfoot, congenital pseudarthrosis of the tibia
3 Trauma sequelae residual poliomyelitis osteochondromatosis
4 Etiology of Overgrowth Post-traumatic overgrowth :femur shaft fracture, tibia shaft fracture Soft tissue overgrowth syndrome :gigantism with neurofibromatosis, Klippel- Trenaunay syndrome, Beckwith-Wiedemann syndrome, Proteus syndrome Idiopathic hemihypertrophy Chronic inflammatory arthritis (ex. RA)
5 Idiopathic hemihypertrophy Klippel-Trenaunay syndrome Neurofibromatosis
6 Mechanism of compensation The child with LLD usually compensates better than the adult. The child can compensate for minor degrees of LLD by walking on the toes of shot leg. The adult seldom compensate that manner- tend to heel-toe gait: vaulting gait & excessive pelvic motion and tilt.
7 Effect in Gait cycle The amplitude of vertical pelvic motion is increased by LLD.
8 Hip - Effect Pelvic obliquity Relatively uncovered hip of long leg and increased coverage of the hip of the short leg. Increased risk of DA of the long leg
9 Effect in the Hip Joint Decreased in CE angle on the long leg side -- decreased in the load bearing area -- causes late degenerative arthritis.
10 Effect in the Spine Low back pain and late degenerative arthritis: controversial LLD- causes increased incidence of scoliosis Severity of the problem -- related to the severity of LLD -- uncompensated or uncorrected -- onset of age
11 Leg-length Patient Assessment-clinical 1)Leg-length -Apparent length : from the umbilicus to the medial malleolus -Real length : from the ASIS to the medial malleolus -Wood block test
12 Apparent length(umd) Real length(smd)
13 Wood block test
14 Leg-length Patient Assessment-clinical 1) Leg-length 2) Pelvic obliquity 3) Angular deformity of the Joint 4) Joint instability
15 Leg-length Radiological Assessment 1)Teleroentgenogram - Single exposure of both leg on a long film - Reveals angular deformity - Error of magnification - Best technique for small children
16 Leg-length Radiological Assessment 2) Orthoradiograph - Exposures each joints individually - Avoiding errors of magnification - multiple exposure
17 Leg-length Radiological Assessment 3) Scanogram - Moving film cassette - Avoid magnification - Cannot assess whole shape of leg
18 Computed Scan Digital Radiograph Scanogram
19 Estimation of skeletal maturity - Bone age - Atlas Sum of scores Statistical combination of scores
20 Bone age -Atlas- Greulich and Pyle atlas (1959) - Rapid interpretation - Few changed in the hand during the critical time of puberty - 성장과정중아이들마다편차가많다. - Interobserver error - Hand or Wrist 의 anomaly 있는경우측정이어렵다.
21
22 Bone age -Scoring system- Tanner-Whitehouse method (1975) - similar to Greulich and Pyle atlas : using hand and wrist X-ray : using computerized mathematical method (using 20 landmarks in the hand and wrist scoring system) - more cumbersome, time consuming.
23
24 명의 16 세까지어린이대상 - TW2 방법
25 Growth Calculation The Arithmetic Method The Growth Remaining Method The Straight line Graph Method The Multiplier method
26 The Growth Remaining Method -growth calculation- Skeletal age More accurate Green and Anderson growth remaining graph (Green & Anderson,1963)
27
28 The Straight line Graph Method -growth calculation- Skeletal age Accurate At least 3 check points needed
29
30
31 The Multiplier method (Paley et al, 2000) -growth calculation- Based on Green and Anderson s growth Graph 한두번의측정으로도비교적정확하게향후예상
32 Lowerlimb multiplier for boys and girls
33 Multiplier method Congenital Limb-Length Discrepancy m = x M ( : Current Limb-length discrepancy m: Limb discrepancy at skeletal maturity) Example) 현재 4cm 차이있는 Congenital hemihypertrophy 10 세남아의최종길이차이는? 4 x = 5.24 cm
34 Developmental LLD m = + (IXG) I=1-(S-S )/(L-L ) G=L(M-1) G= amount of growth remaining I=amount of growth inhibition L= current length of long limb L =length of long limb as measured on previous radiographs Lm=length of femur or tibia at skeletal maturity M=multiplier S= current length of short limb S =length of short limb as measured on previous radiographs = current limb-length discrepancy m=limb length discrepancy at skeletal maturity
35 Right femur epiphyseal infection 을앓은병력이있는 10 세남아로 LLD 를주소로내원하였다. 최종예상 LLD 는? 8 세 10 세 Femur length(cm) right left I =1-(26-24/29-26) = 1-2/3 = 0.33 G= 29( ) = 29 x = 8.99 m = 3 + (0.33 x 8.99) = = 5.97 cm
36 Time of Epiphysiodesis Lm = L x M Lε = Lm Gε Mε=Lm/Lε L= current length of long limb M=multiplier Lm= length of femur or tibia at skeletal maturity ε = desired correction following epiphysiodesis Gε=amount of femoral or tibial growth remaining at age of epiphysiodesis(gε= ε/0.71 for femur and ε/0.57 for tibia) Lε=desired length of bone to undergo epiphysiodesis at time of epiphysiodesis Mε=multiplier at age of epiphysiodesis
37 Right distal femur epiphyseal infection 을앓은병력이있는 10 세남아로 LLD 를주소로내원하였다. 가장적절한 epiphysiodesis 시기는? 8세 10세 Femur length(cm) right left Lm = L(29) X M(1.31) = Lε = Lm(37.99 ) Gε(3/0.71) = = Mε=Lm(37.99)/Lε(33.77) =1.125 multiplier chart 보면 세 세 6 개월따라서가장적절한시기는 13 세 1 개월에해당함.
38 Treatment General Principles 0-2cm: No treatment 2-6cm: Shoe lift,epiphyiodesis,shortening 4-20cm: Lengthening >20cm: Prosthetic fitting
39 Shoe lift Patient who do not wish or are not appropriate for surgery. Lift higher than 5 cm poorly tolerated.
40 Prosthetic fitting Significant discrepancies, deformed functionally useless feet Discrepancies greater than 15-20cm and femoral length less than 50% Fibular hemimelia with unstable ankle PFFD: A/K prosthesis or BK prosthesis with Van Nes rotationplasty Optimal age: syme amputation- end of 1yr Rotationplasty: 3 yr
41 Epiphysiodesis Very low morbidity and complication rate. Slowing growth rate of long leg and allowing short leg to catch up. Suitable for sufficient data to enable a confident prediction of discrepancy at maturity. Tibial epiphysiodesis should be accompanied by arrest of proximal fibular physis if tibial shortening is greater than 2.5cm.
42 Epiphysiodesis Phemister technique (JBJS,1933)
43 Epiphysiodesis Blount (staple) technique (CORR,1949) 12yr/female 1yr 2yr
44 Epiphysiodesis Percutaneous technique (Bowen R, et al,corr,1984)
45 Male/14yr (Sk.age), LLD: 2.5.cm Idiopathic hemihypertrophy
46 Male/14yr Proximal tibia & Distal femur epiphysiodesis, Lt
47 Postop 3 yr
48 Male/14yr Polyostotic fibrous dysplasia Tibial overgrowth, 2cm, right Postop 3 yr
49 Epiphysiodesis PETS(Percutaneous Epiphysiodesis using Transepiphyseal Screws) (Metaizeau JP, et al, JPO,1998)
50 Epiphysiodesis Stevens P, et al. JPO, 2006, plated growth plate
51 Problems of Epiphysiodesis Undercorrection -- growth or angulation Overcorrection -- growth or angulation Rebound phenomenon (staples or screws) Failure of growth restoration Staple breakage or bending
52 Shortening operation Mature patient Tibia< 4cm, Femur< 5cm Neurovascular complication is higher in tibia, fasciotomy is advisable.
53 Neurofibromatosis, F/16 yr LLD, 4cm Genu valgum,lt
54 Femur Corrective osteotomy 1cm shortening Tibia 3cm shortening
55 Preop Postop 2yr
56 Growth stimulation Circumferential release of periosteum Foreign material implanted next to growth plate Sympathectomy Surgical constructed AV fistula Periosteal stripping -- none has been successful enough to be clinically useful.
57 Limb lengthening operation Codvilla(1905) first described limb lengthening Compere & Sofield (1936) Anderson (1952) Wagner (1978) De Bastiani (1986) Ilizarov (1989)
58 Transiliac One stage lengthening - Shortening < 3cm - Acetabular dysplasia Femoral and Tibial Complication -Nerve injury -Artery occlusion -Reflex sympathetic dystrophy -Intraop. fracture -Joint stiffness or subluxation
59 Distraction Epiphysiolysis Chonodrodiastasis (Gelbke,1951, De Bastiani,1986) - Separation of the epiphyseal plate - Immature patient - Risk of septic arthritis - Painful stiffness of the joint - Premature closure of the physis
60 Gradual lengthening - Distraction Osteogenesis- Ilizarov technique 1) Corticotomy: preserve endosteal & periosteal blood supply 2) Ilizarov Ring fixator: permit micro-axial motion 3) Latency period: 7-14 days 4) Proper rate & rhythm: 0.25mm x4 / day 5) Encourage joint motion
61 Gradual lengthening Device for gradual lengthening - Unilateral fixator - Circular ring fixator (Ilizarov, Taylor spatial frame ) - Combined internal and external fixation (Lengthening over IM Nailing) (Lengthening with submscular plate) - Totally implantable lengthening device Albizzia nail ISKD Fitbone
62 Ring fixator Correction of complex deformity (as well as lengthening) Ilizarov Taylor spatial frame
63 Combined Internal and external fixation (Lengthening Over Nail) Shorten the period of external fixation Reducing the rate of regenerate bone fracture
64 Combined Internal and external fixation (submuscular plating after distraction osteogenesis) Oh, CW et al. JBJS Br 2009 :91: Oh, CW et al. JPO B : 265-9
65 Gradual lengthening - totally implantable lengthening device- ISKD Fitbone
66 Gradual lengthening Complication of gradual lengthening : 14%-134% Untoward Events - Paley D,CORR, Problems - not requiring operative intervention to resolve - Obstacles - requiring operative intervention but without permanent sequelae - Complications - intraoperative injury or anything resulting in permanent sequelae
67 Thank you for your attention!
68 Thank you for your attention!
Leg-length discrepancy and Its management
and Its management 성균관의대 삼성서울병원 심종섭 Etiology of Undergrowth Congenital limb deficiency i : Congenital femoral deficiency, congenital fibular deficiency, tibial hemimelia Asymmetrical neurological disorders
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