Limb Length Discrepancy

Limb Length Discrepancy

Limb Length discrepancy is a medical condition due to which the patient suffers a difference between the lengths of their arms or legs. A leg length discrepancy is usually noticeable as a person grows up and it can be a condition that developed at birth or due to some illness or injury; thus, it can cause a length discrepancy to develop over time. While a minor leg length difference may not cause any problems; but a substantial limb difference can cause patients to limp and suffer difficulties in running or other physical activities. It’s not rare to find a mild variation between the two sides of the legs; in fact in a study conducted found that 32% of military recruits suffered from 0.5 cm to 1.5 cm difference, naturally, between their legs. Medically this is considered acceptable and normal; however, any greater limb length difference can affect the patient’s quality of life and overall well-being.

Generally, in most cases patients either Femur (thighbone) or Tibia (shinbone), or both; may have uneven lengths. The growth on our bones happens around the growth plates, which are areas of cartilage located at the ends of our bones; and if the illness or injury damages these growth plates; either bone may grow faster or slower than their opposite leg.

Causes of Leg discrepancy can range from:

• Injury to a bone in the leg - Depending on the severity of the injury the affected bone might be shortened, especially in cases where a bone is broken into several pieces. Similarly, it has been noted that in children a broken bone may heal faster, causing the broken bone to grow longer than the other leg.
• Bone Infection – can slow the growth of bones, especially in infants and younger children.
• Certain Bone diseases (Dysplasias)
  • Neurofibromatosis
  • Multiple hereditary exostoses
  • Ollier disease
• Other Causes may include:
  • Neurologic conditions
  • Conditions that cause inflammation of the joints during growth, such as juvenile arthritis
  • Hemihypertrophy (one side too big) and hemiatrophy (one side too small)
  • In some rare cases, the cause of limb length discrepancy can be "idiopathic," or unknown and this can usually occur in patients who suffered from underdevelopment of the inner or outer side of the leg, or partial overgrowth of one side of the body.

The effects of a leg length discrepancy are variable and depend on several factors including, the exact cause of the discrepancy, to the actual size of the limb length difference. Generally, patients who suffer from a leg difference of 3cm to 6cm may develop a limp while walking; as the limb difference, requires them to exert more effort towards walking and tiring them easily. In severe cases of limb length discrepancy, it may even cause lower back pains and leave the patients more vulnerable to injuries.

 

Treatment Options for Leg discrepancy

To provide a proper diagnosis the medical professional need to consider several factors while planning the patient's treatment, which may including:

• The size of the discrepancy
• The age of the patient
• And the cause of the leg discrepancy, if it is known

The treatment options for such a discrepancy depends on the severity and limb difference; in most cases, a minor leg difference can be managed in several ways from minor surgeries which slow or stop growth in the longer leg to wearing foot support or a shoe lift, in the shorter leg.

However, where the leg difference affects the normal quality of life and daily life of the patient's several surgical treatment options can be opted for, including:

 

1. Epiphysiodesis Surgery

This surgical method can be used to slow down or stop growth at one or two growth plates in the longer leg; by either surgically drilling the growth plate of the longer leg, so that the shorter leg can slowly catch up, and eliminate the discrepancy. Another method of surgery can stop the growth of the longer leg by placing metal devices (Plates and/or Staples) around the growth plate to stop its growth; till the time the shorter leg is equal in length.

The possible drawback with such a procedure could include;

• The possibility of over or under correction of the leg discrepancy.
• The patient cannot achieve their natural maximum height.
• Such surgery can cause an overall disproportionate body aesthetic.

 

2. Limb Length Shortening Surgery

Patients whose growth plates have closed can opt for limb shortening surgery, and their longer limb can be surgically shortened to even out the leg difference. For such a procedure, the doctor surgically removes a section of the bone from its middle, then inserts either an intramedullary nail or an external fixator; or a combination of both; to hold the bone in place while it heals.

All four methods for limb lengthening; i.e. Holy-Fix, LON, Precice 2 & Precice Stryde can be used for limb shortening; the only difference lies that the devices do not distract or extend the limb. However, it must be remembered that limb shortening surgery may weaken the muscles, and cannot be used for significant limb length discrepancies. The maximum safe limit for the Femur (thighbone) is 5 cm and the maximum for the Tibia (shinbone) is 3 cm.

 

3. Limb Lengthening or Extension Surgery

For patients suffering from major limb discrepancy, limb lengthening surgery offers a solution. Such surgery can be performed internally, externally or with a combination of both. In current times, these basic clinical methods have been adopted throughout the world as the basic foundation of all limb lengthening surgeries. They are as follows:

1. External Lengthening Methodology

In this type of surgery, the doctor surgically cuts the bone in the shorter leg into two sections, then affixes an "external fixator" to the operated bone of the leg. The external fixator is a frame that is connected to the bone with wires, pins, or both. The lengthening process begins approximately 5 to 10 days after surgery and is performed manually, by turns the dial on the fixator a few times each day. When the bones are slowly drawn apart (distracted), new bone growth happens in the space created. Furthermore, Muscles, skin and other soft tissues stretch and adapt as the limb slowly lengthens. Generally, the bone may lengthen 1 mm per day or approximately 3 cm per month. The external fixator remains affixed till the time the bone is strong enough to support the patient’s weight safely; which normally takes about one month for every centimeter gained; hence if the patient gained 3 cm, this bone consolidation period will last about 3 months. Furthermore, factors such as age, health, smoking, and participation in rehabilitation can also affect recovery times as well.

1. 1. Ilizarov’s Methodology – The Ilizarov’s surgical method, was developed by a Russian orthopedic surgeon, Gavriil Ilizarov and was first successfully applied in World War 2 and since has been in surgical practice, till today. It is an external only methodology for bone lengthening, whereby the bone is affixed with thin wires and hoops; with an external fixator or Ilizarov’s device. Regular care and maintenance of the device, its wires & screw; is crucial with this methodology. As per the recommendations of medical practitioner’s guidance patients must strictly care and sterilize the devices, its wires, and screws, daily. The biggest problem with this method, apart from the strenuous daily regular care, is the chances of an infection, especially where sterilization is nor carried out daily; since the wounds are open and affixed with wires; the chances of infections increase. The problem is that if an infection does happen, during the lengthening phase; the infections become a priority; thus the lengthening process is halted till the time the infection subsides.
2. 2. The “Holy-Fix” Methodology – This is a fully external methodology; whereby rod-alike external metal fixators are attached to each of the legs of the patients utilizing pins affixed from the outside of the operated bones. During the lengthening stage, patients are required to turn screws on the device, simultaneously on both the treated legs, to achieve their daily distraction of 1mm per day. The only disadvantage that the patients are held with the devices for a period between 9 to 12 months; meaning that they have to walk, sleep and live their daily lives with the devices attached to their treated legs. Furthermore, with this methodology, the devices cannot be removed in the consolidation and strengthening stages, or until the bones fully return to their pre-surgery density and integrity and can fully bear the patient's weight.
3. 3. Potential risks and complications of external lengthening may include:
4. 1. 1. Infection at the site of wires and pins
      2. Stiffness of the adjacent joints
      3. Slight over- or under-correction of the bone's length

 

2. Combinational Lengthening Methodology – Both Internal & External
3. 1. The “LON” Methodology (Combination internal and external) - is almost practiced in similarity with the “Holy-Fix” methodology regime; i.e. that it also involves the use of the same external device, but the major difference is, there are internal intramedullary nails implanted as well, into the bone cavity during operation. This internal nail system, with the help of external distractors, significantly reduces the time spent in lengthening phases. And soon after the lengthening phase is completed the external fixators are removed, and the consolidation & strengthening phase could easily begin. With this combinational methodology and early removal of the external fixators, the patient’s comfort factors dramatically increase and the internal nails can also easily bear the weight of the patients till the time that the bones have fully consolidated. Soon after, these internal nails are surgically removed, with the help of a minor surgical procedure, which lasts around 30 minutes at best. This combination system allows for quicker recovery times, in comparison to “Holy-Fix”; and with better comfort levels for the patients, during the recovery phases.

 

       3. Internal Lengthening Methodology

In such a method of surgery the doctor cuts the bone in the shorter leg, then surgically implants an expandable intramedullary nail into the bone cavity. The nail is completely internally embedded and lengthens gradually, pulling apart the surgical bone gap and new bone growth happens in the gap created. The nails provide stability and alignment to the bone as it lengthens. Furthermore, as there is no need for an external fixator for distraction (lengthening) there is less risk of infection and such a system avoids the physical and psychological challenges that the patients suffer from wearing an external fixator.

1. 1. PRECICE 2 by NuVasive(USA): Unlike methods of limb lengthening which require external fixator devices for distraction, “PRECICE” methodology, is standalone, i.e. it does not need any external fixator, because the intramedullary nail is electromagnetic and motorized, thus allows for bone extensions with just a remote control; providing the patient more comfort and much shorter recovery times in total. Furthermore, the device is internally embedded into the patient’s bone, thus does not cause any discomfort and significantly limiting any risk of infections at a minimum. Moreover, it reduces the total recovery period to just 2.5 months. With “PRECICE”, the surgeon makes a small incision and inserts the motorized intramedullary nail into the bone (either Femur or Tibia), and closes the wound; hence reducing the risk of any open wound infections.
2. 2. “PRECICE STRYDE” by NuVasive(USA) is the latest limb lengthening system available, it builds upon the “PRECICE 2” system, and provides full weight-bearing capabilities3; hence increasing the patient's comfort levels and providing a shorter recovery time of 2.5 months. Furthermore, the “STRYDE” nails are made of stainless steel, which can easily bear the weight of the patient during the distraction phase, allowing them much more mobility.

It must be kept in mind that both internal and external lengthening take several months to complete and fully recover and both procedures require:

• Regular follow-up doctor's consultation
• Extensive rehabilitation, including physical therapy and home exercise

 

It is quintessential that an experienced orthopedic surgeon is chosen for limb lengthening, who can guide the patients about the techniques and their treatment options with a thorough explanation of the risks and benefits of both internal and external limb-lengthening. Usually, for correctional and discrepancy surgeries, a doctor's initial consultation becomes necessary for the patient to decide the procedure and method of the surgery.

Cost of Limb Discrepancy Surgery:

1. Singular Limb (either Femur Or Tibia) Lengthening surgery for limb discrepancy correction, with:
2. 1. Holyfix method: 8,000 Euros
   2. LON method: 9,000 Euros
   3. Precice 2: 18,000 Euros
   4. Precice Stryde: 29,000 Euros

 

2. Bow Legs Correctional surgery: 7,500 Euros

 

3. For more information about limb length discrepancy and other types of limb correctional surgeries and treatments please contact our patient consultants and visit our doctor's page: https://www.bulmd.com/doctors

 

4. Moreover, for a thorough, healthy and smooth treatment experience, we provide the following facilities, which are included in the total price that we charge for the surgeries:

• Meeting and greeting our patients at the airports, including all transportation, to and from their hotels & hospitals
• Accommodation in a 5-star hotel (1 to 3 days)
• An English-speaking caretaker who will assist our patients 24/7
• A Complimentary Istanbul tour, including historical and touristic visits, boat tours and meals in our famous Turkish restaurants
• All necessary medical examinations before the surgical operation
• 5 to 7 days of hospitalization
• Physiotherapist’s assistance and all medications are covered, during the patient’s hospitalization
• Walkers, crutches & wheelchairs
• Transportation to the airport upon departure
• FREE consultation with doctors and consultants, whenever the patient’s needs, even after the lengthening process has been completed.

 

5. Please note that this stated price also includes the following costs, besides the surgery itself: 

• All hospital charges relating to the operating room and recovery room.
• Surgeon fees.
• Anesthesiologist fees.
• Surgery assistant fees.
• Hospital fees (Internal medicine doctors will be available during the entire hospitalization period).

 

For more information regarding Limb Length Discrepancy and Correctional Surgeries, please contact us at [email protected] 

Or 

For direct consultation, please contact our expert patient consultants via phone or WhatsApp: +90 531 988 3090