ARTICLE IN PRESS

Management of Mild Lower Extremity

Deformity and Leg Length Discrepancy
Alexander L. Kuzma, MD, and L. Reid Boyce Nichols, MD, FAOA, FAAOS

Limb malalignment and length discrepancy are common problems treated by pediatric
orthopaedic surgeons. These deformities may increase the rate of degenerative disease of
the knee, hip, and spine. Previous teaching suggested that there were no long term conse-
quences of mild deformity, however, newer studies suggest that there may be morbidity
associated with as little at 5 mm of leg length discrepancy. There are many etiologies that
can contribute to limb deformity, and so a thorough history and physical is key to manage-
ment. Pediatric patients present the unique opportunity to utilize the growth of the physis to
correct these deformities with adequate planning. Alternatively, lengthening techniques
have become safer and are associated with excellent patient satisfaction. The mounting evi-
dence of the long term consequences of leg deformity, coupled with more sophisticated
correction techniques, brings traditional indications for deformity correction into question.
Oper Tech Orthop 00:100874 © 2021 Elsevier Inc. All rights reserved.

KEYWORDS LLD, limb, length, discrepancy, lengthening, deformity

Introduction inches and is not complicated by a deviation of the static axis of

the limb does not require operative treatment”.2 In 1978, a sur-
Malalignment vey of 74 patients with leg length discrepancy greater than
The alignment of the limb is defined by the mechanical axis. 1.5cm was performed.3 The survey consisted of only four ques-
This is formed by a line passing from the center of the femo- tions regarding patient perceptions and presence of back pain.
ral head to the center of the ankle (Fig. 1). This line normally The authors concluded that leg length discrepancy less than
passes through the center of the knee joint. Deviation from 2cm was unlikely to be symptomatic. This study has been
the mechanical axis can be quantified to describe the mala- widely adopted in orthopaedic practice as a minimum indica-
lignment deformity. 1 tion for intervention. However, this study does not represent
definitive level I evidence.

Leg Length Discrepancy

Anatomy and Pathogenesis
A difference in leg lengths is common in the normal population.
The physis serves as the site of endochondral bone formation
The management of leg length discrepancy (LLD) can largely be
and is responsible for longitudinal growth of the long bones.
stratified by the magnitude of difference. In 1921, Vittorio Putti
The histologic zones of the physis have been well described
stated that “shortening of the femur which does not surpass 2
(Fig. 2) and an appreciation of the different growth potentials
Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for in the various physes of the lower extremity is essential to
Children, Wilmington, DE. treatment of limb deformity (Fig. 3). Different pathology
Conflict of Interest: Alexander L. Kuzma, MD: Nothing to disclose. may preferentially affect different zones of the physis. Physeal
L. Reid Boyce Nichols, MD, FAOA, FAAOS: Consultant/Speaker Orthofix, injury can occur due to a number of causes including trauma,
Orthopaedics, Smith & Nephew. Nothing to disclose pertinent to this paper. ischemia, and infection, among others. The Heuter-Volk-
Address reprint requests to L. Reid B. Nichols, MD, Department of
Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, 1600
mann principle states that mechanical forces modulate
Rockland Rd, Wilmington, DE 19803 E-mail: Reid.nichols@nemours. growth at the physis. Specifically, compression slows growth,
org and tension may increase growth.5 40-50% of the variability

https://doi.org/10.1016/j.oto.2021.100874 1
1048-6666/© 2021 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 A.L. Kuzma and L.R.B. Nichols

Figure 2 Growth Zones of physis. Scheme of organization of the

growth plate, or physis. The histologically identifiable layers include
the resting or germinal layer and the proliferative, hypertrophic, and
provisional calcification layers progressing from epiphysis to meta-
physis. Reproduced with permission.1

malunion of 5 degrees or more. 58% of those with malunion

developed osteoarthritis over 15 years of follow-up versus 31%
of those with less than 5 degrees of malalignment (p = 0.02).8
Another study reported on a cohort of 52 femoral fractures, 21 of
whom went on to malunion with angulation greater than 10
degrees.9 6 of the 21 patients with malalignment developed oste-
oarthritis over 21 years of follow-up. The authors reported a posi-
tive correlation between coronal (r = 0.57, p < 0.001) and sagittal
(r = 0.44, p = 0.008) malalignment and osteoarthritis.
Figure 1 Mechanical alignment superimposed on long leg radio-
graphs. The patient has a 2.8cm leg length discrepancy. Mechanical Natural History of Leg Length Discrepancy
alignment is near normal with mechanical axis passing through the
center of the knee joint. Leg length discrepancy is common in the general population,
and the consequences of small leg length discrepancies are
unclear. In a cohort of 247 asymptomatic patients, 53 had leg
in growth rate between physes is from chondrocyte hypertro- length discrepancy with the average magnitude of 5 mm.10 In a
phy, 30-40% is from matrix synthesis, and 10% is from meta-analysis including 573 patients in the general population,
chondrocyte proliferation. This study found that mechanical 90% had a leg length discrepancy of 1 mm or greater (Fig. 4).11
loading affects chondrocyte hypertrophy more than prolifera- Although leg length discrepancies of less than 2 cm are com-
tion. Combining estimates of skeletal age with the growth mon, the consequences of these small differences remain contro-
potential of a given physis is key to planning corrective sur- versial.12 Gross surveyed 74 adults with LLD of 1.5 cm or more.3
gery in pediatric patients. Patients with LLD less than 2 cm were significantly less likely to
consider the discrepancy a problem or feel unbalanced compared
with patients with greater discrepancy. Soukka et al. reported no
Natural History of Malalignment significant relationship between LLD less than 2 cm and low
Dysfunction in the lower extremities such as malalignment or leg back pain.10 Tallroth et al. followed this same cohort for 29 years,
length discrepancy can lead to early joint degeneration. In 1991 a however, and found that patients with LLD greater than 1 cm
cadaver study demonstrated that malalignment increased articu- had a three times higher rate of undergoing total knee arthro-
lar pressure.6 Both the magnitude and location of deformity were plasty.13 Harvey et al. examined the Multi-center Osteoarthritis
important factors, with 20 degrees of proximal tibia varus increas- Study prospective cohort, and found that patients with LLD to
ing medial compartment pressure by 106%. A clinical study be at increased risk for knee osteoarthritis.14 This effect held true
reported on a cohort of 17 patients with Blount’s disease that for as little as 5 mm of discrepancy. Another study reviewed all
found the incidence of arthritis increased by magnitude of defor- primary total hip arthroplasties performed in a single institution
mity.7 In a cohort of 88 tibial fracture patients, 43 went on to over 2 years, and found that in a cohort of patients with mean
 ARTICLE IN PRESS
Management of Mild Lower Extremity Deformity and Leg Length Discrepancy 3

Figure 3 Approximate percentage of longitudinal growth provided by the proximal and distal physes at each long bone
in the upper (A) and lower (B) extremities. Reproduced with permission.4

Figure 4 Prevalence of LLD. The prevalence of various magnitudes of

leg length discrepancy within a cohort of 573 patients. Reproduced
with permission.11 https://creativecommons.org/licenses/by-nc/4.0/

7.5 mm LLD, the longer leg was a significant predictor of the side
of operation.15 Murray et al. found leg length discrepancy of
5 mm or more to be significantly associated with hip osteoarthri-
tis as well as degenerative disease of L5-S1.16 Gurney et al. simu-
lated the effects of LLD in formal gait analysis and noted
increased oxygen consumption and exertion with a 2 cm lift Figure 5 Full length lower extremity x-rays demonstrate leg length
added to healthy volunteers.17 discrepancy in a 16 year old male with a history of left distal femur
physeal fracture. Measurement reveals 3.5cm LLD.
Patient History and Physical Findings

 Careful assessment of joint motion supine and prone

 History primary complaint. Causative factors  Block test correction to level pelvis
 Gait toe walking, pelvic tilt, knee flexion, vaulting,  Rotational profile prone hip rotation, thigh foot
circumduction angle, transmalleolar axis
 ARTICLE IN PRESS
4 A.L. Kuzma and L.R.B. Nichols

 Neurovascular exam
 Recognize underlying syndromes
 Recognize soft tissue contractures
 Maximize bone health (calcium, vitamin D, nutrition)
and correct underlying endocrine factors

Imaging and Other Diagnostic Studies

 Full length standing x-rays. AP and Lateral. Magnification

marker, knees in full extension, level pelvis (Fig. 5).
 Hand x-ray for calculation of bone age (Fig. 6).
 CT Scanogram to assess rotational profile, also useful if
soft tissue contracture present. Selective CT scan cuts
can reduce radiation exposure (Fig. 7).
Figure 7 CT scanogram of 10 year old female with metaphyseal-
epiphyseal dysplasia and complex multiplanar deformity of the left
Treatment Options lower extremity.

Nonoperative
A shoe lift is the traditional non-operative management for leg
length discrepancy. A meta-analysis of patients with LLD and Operative Management of Malalignment
either low back pain, scoliosis, hip pain or knee pain found a Growth modulation represents a unique opportunity to
shoe lift alleviated pain in 88% of subjects.18 Shoe lifts are not harness the potential of the physis in pediatric deformity
always well tolerated by patients, whether due to limited shoe- correction. Multiple techniques to correct angular defor-
wear options or cosmesis, and are not always an appropriate mity have been described, including permanent hemiepi-
treatment. In patients with significant malalignment, there is physiodesis versus reversible methods utilizing staples,
little role for observation alone as the definitive treatment. screws, or tension band plating. In a multicenter cohort
of 537 patients undergoing tension band plating, the
average correction rate was found to be 0.77° per month
in the distal femur and 0.79° per month in the proximal
tibia.19 Overall successful correction was 70% with femo-
ral deformities and 80% with tibial deformities. Tension
band plating for hemiepiphysiodesis has become increas-
ingly popular, however, there is a risk of failure both due
to hardware breakage as well as undercorrection. A
review of this technique recommended caution in older
patients with large deformity (> 20°) or obesity (BMI >
35). 20 These patients may be better served with an osteot-
omy with acute or gradual correction.

vOperative Management of Leg Length

Discrepancy
Determination of skeletal age is an important step for accu-
rate deformity correction. In a series of 77 patients, chrono-
logic age was discrepant from skeletal age by greater than 1
year 26% of bone age radiographs.21 In that series, use of
skeletal age reduced prediction errors compared to chrono-
logical age.
The next critical step of pre-operative planning con-
sists of determining future deformity. Multiple methods
of predicting future leg length discrepancy have been
described including the arithmetic method, growth
remaining method, straight-line graph method, and mul-
Figure 6 Bone age x-ray in a 12 year old male with bone age tiplier method. Makarov et al. compared these methods
12.5 years by Greulich and Pyle atlas. in a cohort of 77 patients, and recommended use of the
 ARTICLE IN PRESS
Management of Mild Lower Extremity Deformity and Leg Length Discrepancy 5

Figure 8 Author’s preferred treatment algorithm for leg length discrepancy based on magnitude of deformity.

Figure 9 Long leg alignment views demonstrate 2.8cm discrepancy

between limbs with left side short.

arithmetic method with both increased accuracy and ease

of use.21 Little et al. reviewed a series of 71 epiphysiode-
sis cases, using various planning methods, and found
27% of patients had residual leg length difference of 2 cm
or greater. 22 Therefore, even with proper planning,
undercorrection remains a risk.
Figure 10 Bone age x-rays demonstrate skeletal age 14. The patient is
Epiphysiodesis often presents an ethical quandry for
skeletally mature with little growth remaining.
patients, families and clinicians during discussion of treat-
ment options. The concept of shortening the “normal”
limb to correct deformity, and the resultant loss in Author’s Preferred Treatment
expected height, can be challenging to accept. Height has Algorithm
been linked to social esteem, leader emergence, perfor-
mance, and income.23 A full discussion of treatment Important considerations for patient management include
options for leg length discrepancy includes not only epi- symptoms, skeletal maturity, and magnitude of deformity
physiodesis but also acute shortening and lengthening, (Fig. 8). There is certainly evidence that small leg length dis-
whether intramedullary or extramedullary. crepancy can lead to symptoms, and using only absolute
Traditional methods of limb lengthening over external number cut-offs may lead to sub-optimal outcomes. Though
fixators were fraught with complications of soft tissue con- limb equalization for greater than 2cm is generally accepted,
tracture, scarring, and pin site infections. A recent devel- the evidence suggests symptomatic patients with LLD >1cm
opment in the science of limb lengthening is the advent of may also benefit from correction.
magnetically controlled intramedullary lengthening nails. Growth modulation is an important tool in the current era
Intramedullary lengthening devices were associated with of limb lengthening, as it can be used primarily for correction
less pain, improved cosmesis and improved patient satis- or as an adjunct to lessen the amount of lengthening neces-
faction compared to extramedullary techniques.24 These sary. Growth modulation is limited by the opportunity of
devices were found to have a correction accuracy of 94% growth remaining, and so this is not an option in skeletally
and precision of 86% in one cohort.25 mature patients.
 ARTICLE IN PRESS
6 A.L. Kuzma and L.R.B. Nichols

Figure 11 Treatment course over 1 year showing correction with lengthening rod. A. Presentation. B. 2 weeks post-
operative. C. 4 weeks post-operative. D. 6 weeks post-operative. E. 10 weeks post-operative. F. 14 weeks post-opera-
tive. G. 7 months post-operative. H. Hardware was removed at 1 year post-operative. Leg lengths corrected and osteot-
omy healed.

Hemiepiphysiodesis can also correct malalignment to Conclusion

allow intramedullary lengthening, which is generally pre-
Pediatric patients present the unique opportunity to utilize the
ferred by patients. Again, this is limited by growth remaining.
growth of the physis to correct lower extremity angular defor-
In skeletally mature individuals with both LLD and malalign-
mities and length discrepancies with adequate planning.
ment, we typically use circular external fixation in order to
Mounting evidence suggests that even mild malalignment and
address all deformities present.
leg length discrepancy can increase risk for long term muscu-
Finally, patients present with preconceived bias regarding
loskeletal degenerative pain. Treatment options for these
treatment. For instance, some patients may be averse to loss
deformities have evolved to become more precise and carry
in height implied with growth modulation techniques. A full
less morbidity for the patient. Future studies will help us iden-
discussion of all treatment options, risks, and benefits, as
tify ideal indications for deformity correction, and, meanwhile,
well as incorporating patient goals in decision making, is key
it is important to question historic thresholds for intervention.
to success.

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