Restoration of Native Leg Length After Opening-Wedge High Tibial Osteotomy: An Intraindividual Analysis

Background: Opening-wedge high tibial osteotomy (OWHTO) has been shown to significantly increase leg length, especially in patients with large varus deformity. Thus, the current literature recommends closing-wedge high tibial osteotomy to correct malalignment in these patients to prevent postoperative leg length discrepancy. However, potential preoperative leg length discrepancy has not been considered yet. Hypothesis: It was hypothesized that patients have a decreased preoperative length of the involved leg compared with the contralateral side and that OWHTO would subsequently restore native leg length. Study Design: Case series; Level of evidence, 4. Methods: Included were 67 patients who underwent OWHTO for unilateral medial compartment knee osteoarthritis and who received full leg length assessment pre- and postoperatively. Patients with varus or valgus deformity (>3°) of the contralateral side were excluded. A musculoskeletal radiologist assessed imaging for the mechanical axis, full leg length, and tibial length of the involved and contralateral lower extremity. Statistical analysis determined the pre- and postoperative leg length discrepancy and the influence of the mechanical axis. Results: Most patients (62.7%) had a decreased length of the involved leg, with a mean preoperative mechanical axis of 5.0° ± 2.9°. Length discrepancy averaged –2.2 ± 5.8 mm, indicating a shortened involved extremity ( P = .003). OWHTO significantly increased the mean lengths of the tibia and lower limb by 3.6 ± 2.9 and 4.4 ± 4.7 mm ( P < .001), leading to a postoperative tibial and full leg length discrepancy of 2.8 ± 4.3 mm and 2.2 ± 7.3 mm ( P < .001 and P = .017, respectively). Preoperative leg length discrepancy was significantly correlated with the preoperative mechanical axis of the involved limb ( r = 0.292; P = .016), and the amount of correction was significantly associated with leg lengthening after OWHTO ( r = 0.319; P = .009). Patients with a varus deformity of ≥6.5° (n = 14) had a preoperative length discrepancy of –4.5 ± 1.6 mm ( P < .001) that was reduced to 1.8 ± 3.5 mm ( P = .08). Conclusion: Patients undergoing OWHTO have a preoperative leg length discrepancy that is directly associated with the varus deformity of the involved extremity. As OWHTO significantly increases leg length, restoration of native leg length can be achieved particularly in patients with large varus deformity.

Surgical Treatment of Leg Length Discrepancy and Knee Flexion Contracture Associated with a Congenital Absence of Quadriceps

We report the case of an 18-year-old male with congenital absence of quadriceps and hypoplasia of the patella who presented with a significant leg length discrepancy (LLD) and knee flexion contracture. Surgical management was aimed toward lengthening the limb, stabilizing the joint, and correcting the knee flexion contracture. Correction of a significant congenital LLD and knee flexion contracture poses challenges due to long-standing altered biomechanics. These are rare conditions for which no accepted surgical algorithms exist. It is essential to anticipate the biomechanical consequences of limb lengthening and flexion contracture correction that might arise and plan comprehensive interventions accordingly.

Leg length discrepancy: A systematic review on the validity and reliability of clinical assessments and imaging diagnostics used in clinical practice

Background A variety of assessments to determine leg length discrepancy (LLD) is used in clinical practice and evidence about validity and reliability may differ. Objective The objective of this systematic review was to identify and describe the validity and reliability of different assessments and imaging diagnostics for the determination of LLD. Materials and methods The review was conducted following the recommendations of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The databases Medline (PubMed) and Index to Chiropractic Literature were systematically searched. Studies regarding clinical assessments and imaging diagnostics for the diagnosis of LLD, which reported the clinimetric properties for assessment of LLD, were included and screened for methodological quality using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool for validity studies and the Quality Appraisal of Diagnostic Reliability (QAREL) tool for reliability studies. Results Thirty-seven articles on clinical assessments and 15 studies on imaging diagnostics met the eligibility criteria. Thirteen studies on the validity of clinical assessments and six studies on the validity of imaging diagnostics had a low risk of bias and low concerns regarding applicability for all domains. One study on the reliability of clinical assessments and one study on the reliability of imaging diagnostics had a low risk of bias. Main limitations were, that an analysis of sensitivity and specificity was only performed in a few studies and that a valid reference standard was lacking in numerous studies on clinical assessments. Conclusions For the clinical assessment of LLD, the block test appears to be the most useful method. Full-length standing anteroposterior radiography seems to be the most valid and reliable method and may be used as global reference standard to measure the anatomic LLD when comparing clinical methods and imaging diagnostics.

Guided Growth in Leg Length Discrepancy in Beckwith-Wiedemann Syndrome: A Consecutive Case Series

Beckwith-Wiedemann Syndrome (BWS) is a rare genetic disorder characterized by overgrowth, macroglossia, abdominal wall defects, neonatal hypoglycemia, predisposition to embryonal tumor, lateralized overgrowth, and leg length discrepancy (LLD), which can affect normal posture and gait. Aim of this study was to evaluate the effects of guided growth (temporary epiphysiodesis technique) as LLD management in BWS patients. Between 2007 and 2021, 22 BWS patients (15 F, 7 M) with a mean age of 7.9 years (2.9–14.4) and a mean LLD at first surgery of 3.65 cm (2–10), underwent temporary proximal tibial (PTE) and distal femur epiphysiodesis (DFE). In 18 patients the first surgical procedure was PTE, in one, DFE, and in 3 cases, PTE and DFE at the same time, respectively. Eleven patients reached equality of leg length after a mean follow-up of 7.7 years (3.7–13.0) and mean age of 13.3 years (12.7–27.5); 10 patients underwent 3 surgical procedures, one 7 procedures. Fifteen patients had no complications. No severe complications, infection, articular stiffness, or neuro-vascular lesions occurred in remaining patients; complications included secondary varus or valgus axial deviation in a total of 6 patients, and two screw breakages in two patients. Guided growth as a minimally invasive procedure seems efficient for LLD treatment with low complication rate in BWS patients.

Clinical Features of Congenital Pseudarthrosis of the Tibia in Children：a Study Focusing on 514 Cases in China

Background: Congenital pseudarthrosis of the tibia (CPT) is a refractory and rare disease. Because of its extremely low incidence, little is known about its clinical features. In this retrospective study, the aim of this study was to analyze the clinical characteristics of patients with CPT. Methods: This is a retrospective study of children with CPT identified by radiological review. Investigations of CPT included general condition, the characteristics of CPT, treatment methods and surgical complications. Results: We have collected 514 CPTs from 1999 to March 2020 in our hospital, 317 (61.67%) boys, 197 (38.33%) girls; 330 (62.86%) in Crawford IV; 510 (97.14%) in mid and distal 1/3 tibia; 481 (93.58%) in less than 3 years of first appearance of symptom; 297 (57.78%) in less than 3 years of the first visit of outpatient. The most common postoperative complication was ankle valgus (101, 39.60%), followed by limb length discrepancy（91, 35.69%), refracture (38, 14.90%), osteomyelitis (15, 5.88%) and removal of internal fixation (10,3.93%) . Conclusions: CPT with higher incidence of Crawford IV frequently occurs in boys and middle or distal part of the tibia; most patients have the first appearance of symptom and the first visit of outpatient before 3 years; the major surgical complications were ankle valgus and limb length discrepancy.