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SHORTENING. FOR. LEG. LENGTH. DISCREPANCY. N. S. BROUGHTON,. B. W. OLNEY. M. B. MEN. ELAUS. From the Royal. Children's. Hospital,. Melbourne.
TIBIAL

SHORTENING N.

FOR

S. BROUGHTON,

From

Over a 25-year leg length discrepancy cosmetic The

We

present

in only

to the foot procedure

epiphyseal uncertain

the

after

Royal

OLNEY.

Children’s

M.

Hospital,

two cases.

The only

vascular

tourniquet

removal

in one

complication

when

performed

at

Melbourne over a 25-year the literature is there a

procedure

and

PATIENTS

AND

1961 and of the tibia

1984, 12 and fibula

six-and-a-half years. The seven reviewed

length

(including patient on

its long-term

results.

principally

Indication and fibular

were

was

by the sporting

shortening, ability.

measured

weakness;

questioned

and permanent concern over

and

radiographs

as to muscle abnormal

and Residual

examination and

its leg made

photographs

to any

for tibial which is

18 years

Operative technique incision step-cut

the

of age,

242

B. Menelaus. Joint

Surgery

has

been

leg length from 2 to 7.5 cm were generally,

epiphyseal arrest. thirteen-and-a-half

shortening

In

at the age of four

and one at the be discussed.

age

of

ends from

of the tibial steps and, through a separate incision, the shaft of the fibula. The leg is then shortened and

the

be an overlap to the

of from

shortening

tibial fragments In one patient

5 to 7.5 cm.

required

A length

of

from

the

is excised

stabilised by two (Case 6), shortening

screws was

(Fig. 2). performed

by excising 2.5 cm of bone from the midshaft of the tibia and applying a 4-hole plate which was removed at three months. Two years later, a further 2.5 cm was excised by osteotomy

which

was

held

by a single

screw.

Neither of these two methods of shortening recommended. All patients had the tibia in plaster for six all the step-cut

osteotomies

Correspondence

and

had

old for between

is certainly there

will

that

M.

when

equal

On close

Bone

procedure

for it is

bone

I shows

Mr.

The

or when

technique. In all but one patient, a step-cut was employed (Fig. 1), through a longitudinal over the anteromedial surface of the tibia. The osteotQmy is performed so that, after shortening,

review.

to

too late

present arrest,

alternative

one

latest

be sent

knee.

too were

Table

should

they

surgical

N. S. Broughton, FRCS, Clinical Research Fellow B. W. Olney, MD, Clinical Fellow M. B. Menelaus, MD, FRCS, FRACS, Director of Department Department of Orthopaedic Surgery, Royal Children’s Hospital, Flemington Road, Parkville, Victoria 3052, Australia.

1989 British Editorial Society of 0301 -620X/89/2073 $2.00 J Bone Joint Surg [Br] l989;71-B:242-5.

of the

there

weeks;

©

in return

overgrowth of the limb. Pre-operative discrepancy, mainly in the tibia, ranged and the patients suitable for shortening

an oblique

and age for operation. The indication shortening is leg length discrepancy

delay

and again at the age of six years, eight years, for reasons that will

patients had surgical ; one on two occasions.

patients

below

superior

though not invariably, our series, 10 patients

METHODS

temporary and parental

produced stride and

discrepancy

for any muscle were taken.

was temporary

epiphyseal

shortening,

of tibial

up thus : one for six months, one for nine one for two years, one for three years and one for

proportions influence

shortening of the tibia and fibula for normal function and there was minor

in patients

of tibial

for discrepancy

Seven of these patients have recently been reviewed. Five patients, all operated on over 1 3 years ago, could not be contacted ; hospital records showed that they had been

symptoms weakness),

Melbourne

timing for correction.

results

is valuable

ELAUS

patient.

and

followed months,

B. MEN

length

of the

Between shortening

DISCREPANCY

arrest, when there is doubt as to the appropriate at an earlier stage whether there is need for surgical

the Royal Children’s Hospital, period, because nowhere in description

B. W.

LENGTH

period, 12 patients had from 2.5 to 5. 1 cm operative at between four and 18 years of age. All recovered

impairment

circulation

the

LEG

united

in that

are to

12

period.

RESULTS

tibia

could

on by the hypertrophy

be seen

all patients and

felt,

patients. Two of the leg (Cases THE

had

inspection

JOURNAL

normal some

but

this

function thickening

was

never

at the of the

remarked

patients with congenital 6 and 1 1), had the expected OF

BONE

AND

JOINT

SURGERY

TIBIAL

SHORTENING

FOR

LEG

LENGTH

DISCREPANCY

degree

243

of increased

bulkiness

of the

calf

(Figs

3 and

4),

and two patients had slight valgus angulation of the tibia (9#{176} in Case 5 and 7#{176} in Case 7). All patients had had some calfweakness for three to nine months after cast removal but at latest review no patient complained of weakness below

the

knee

below-knee

or

had

muscle.

international

demonstrable

One

weakness

patient

basketball

(Case

within

two

of any

4) was

years

playing

of operation.

DISCUSSION We

could

find

shortening that fear persistent

no

reports

of the

unnecessarily discouraged warned against metaphyseal difficulties mobility He

in closing of soft tissue

advocated

I

Fig.

Figure I Step-cut shortening tihula. The shaded areas are radiograph eight weeks after

ofthe tibia with removed. Figure operation.

not exceed described.

2 excision ofa segment of 2 Case 4. A typical

Using

;

no series

valgus,

segment Clearly, vascular

using

shortening nor

tibial

and, all

results

were

shortening

gave

in our

series.

All

from

two

with

apart

had

an should

a satisfactory

cosmetic

angulation can be avoided by ensuring that axis of the step-cut is parallel to that of

of vascular

problems

none of our patients vascular complication. of

the

12 patients

function

residual

return followed

that

of patients

in all

normal

tibia. Fear

felt

technique,

results

result. Valgus the longitudinal

shortening

and

a step-cut

achieved

the

step-cut It seems and of calf has

the wound caused by the limited at the proximal third of the tibia.

nail 4 cm

satisfactory minor

of

surgeons. Wagner (1977) shortening because of

diaphyseal

intramedullary Fig.

technique

of the tibia or its long term results. of Volkmann’s ischaemic contracture, weakness and over-bulkiness of the

had

has

foot circulation after 4. 1 cm of shortening

to be excised), the surgeon must complications.

Intra-operative

been

expressed,

but

any residual disability In Case 1 1 , some delay tourniquet (the second

but there be alert

fracture

from a in the removal longest

was full recovery. to the possibility of

of a long

narrow

step

was

seen in two patients; this should be avoided by careful carpentry and gentle handling. Ugly scars (two of ours required revision) should be avoided by meticulous wound

closure Ten

with

of our

epiphyseodesis

subcuticular

I 2 patients : tibial

sutures.

were

too old

shortening

was

the patient was presented too late, to the timing for epiphyseodesis, doubt

Fig.

(ase

6. Girl

aged

3 19 years,

Fig. 15 years

years after the second and one shortening. There is 2 cm residual she is unaware. She has normal

VOl..

71-B.

No

2. MARCH

1989

after

the

year after overgrowth function.

first

4

tihial

sub-trochanteric ofthe right

shortening, femoral leg, ofwhich

13

about

the

need

discrepancy.

One

patient

age

years.

of eight

for (Case

A fibular

for treatment

performed

by

because

or there was doubt as or because of earlier

surgical 12) had hemimelia

correction shortening on

the

of

the

at the opposite

side had been effectively treated by the Gruca procedure, and at eight years he had 7.5 cm of leg discrepancy. The affected ankle would not allow compensatory equinus: immediate reduction of the discrepancy was required. Tibial shortening halved the leg length difference and allowed

a reasonable

gait.

B. W. OLNEY,

N. S. BROUGHTON,

244

M. B. MENELAUS

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. THE

JOURNAL

OF BONE

AND

-C 1-

JOINT

SURGERY

TIBIAL

SHORTENING

FOR

LEG

LENGTH

DISCREPANCY

245

mentioned, we do fixation or the short in her

not recommend oblique osteotomy

either the techniques

plate used

case.

The

indication

for shortening

ing the opposite tibia is preferable to perform overgrowth thereby shortening

(Cases

requires tibial

2, 6 and

restored. should

rather

than

lengthen-

consideration. Clearly, it shortening ifthere is tibial 1 1); normal

It is more be advised

debatable when

proportions

are

whether tibial the contralateral

tibia is pathologically short. We have done this for patients with contralateral below-knee shortening from 2 to 7.5 cm, aiming to reduce the discrepancy to below that which

would

require

a shoe

Thus

reduction

2.5 cm or less. tibia

varied

from

was always unacceptable the stride ofthese 5

All

the shortened significant morbidity We find this

patient

(Case

four and six years. gross, unsightly affected

the

6) had

shortenings

She had a vascular discrepancy (Figs

entire

leg

and

at the

abnormality 3 and

ultimately

ages

stage

confirmed

VOL.

7I-B.

and

at a later

an excellent

No.

2. MARCH

result.

1989

age,

but

Despite

unduly

;

no patient

problems, one

the contralateral this did proportions

(Fig. 5). of our

and

not

were

patients

engage

to

tibia produce or shorten

commented they

-

operated

on either not noticeable in

normal

4)

required

our

limb. disability

Tibial and

shortening also has

clearly leaves no a much lower

and complication rate than tibial lengthening. results encouraging and will continue to use

technique

for

the

indications

we

have

outlined.

of

with a which

No benefits commercial article.

in any party

form have been related directly

received or will be received or indirectly to the subject

from a of this

5 cm REFERENCE

shortening of the femur. Her two-stage tibial shortening, which totalled 5 cm, could perhaps have been performed at one

shorter; in body

a limp

of the

sporting activities and one plays international basketball; the exception is the patient with fibular hemimelia, and limitation ofactivity here is due to this leg and not to

Case 3. A boy had shortening and gross wasting of the left calf in association with a severe arthrogrypotic foot deformity. Four years after 3.2 cm tibial shortening on the right he has no complaints about the function or appearance of the operated leg, is well proportioned as regards below-knee to aboveknee length, and plays tennis and other sports.

One

length

reviewer but

or produce

in length

2.5 to 5. 1 cm and

somewhat alteration

potential

to the Fig.

raise

recent

review

this,

as previously

has

Wagner H. Surgical lengthening technique and indications. discrepanc;’ : the injured knee. I. Berlin etc: Springer-Verlag,

or shortening of femur and tibia: In: Hungerford DS, ed. Leg length Progress in orthopaedic surgery Vol 1977:71-94.