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.
