Limb Lengthening & Deformity Correction
Introduction
The lower limb deformities include a group of disease affecting hips, knees, ankles and feet. The condition can be congenital or develop after birth. In addition to cosmetic concern, children with lower limb deformities often have physical limitations due to gait irregularities and pain if left untreated. Lower limb deformities can also have a substantial impact on the quality of life for the children, and can further lead to behavioral, emotional, psychological and social adjustment problems.
Why do you choose our hospital?
The goal of our pediatric orthopedic team is to provide the most technologically advanced treatments to those who suffer from congenital, developmental, and post-traumatic orthopedic conditions. We have experienced nation-class surgeons who perform high volume of surgeries every year. Physicians and specialist in Taiwan frequently refer their patients to our institute particularly when the diagnosis is unclear, the procedure is complicated, or even the most common conditions warrant the best of care. We have built a coordination team formed by pediatric orthopedic surgeons, pediatrician, neonatologist, pediatric nurse, psychologist and physical medicine and rehabilitation specialists. Our patient care coordination team will provide personalized and thorough approach to achieve the right diagnosis and the right access to care. We focus not only on the disease but also on the patient. Patients and their families can trust they will receive the world-class comprehensive medical care in our institute.
What conditions do we treat?
Limb length discrepancy
・Summary
Limb length discrepancy (LLD) refers to the presence of legs that vary in length. This is a common deformity that has no effect on the function of the legs in very mild cases. However, larger variations can affect mobility and function. The condition can result from previous trauma, infection, tumor, congenital musculoskeletal disease or just occur naturally as the child develop.
The first step of approaching LLD would be establish the accurate etiology and treat the underlying problem, such as infection, endocrinology or genetic disease, with our medical coordination team. After treatment completed, the procedure for LLD correction will be arranged.
・Surgical options
For patients with growth potential remaining, a minimal invasive surgery to modulate the knee growth plate can be considered. A mini plate or screw would be temporarily implanted to the knee growth plate at the longer side to halt its growth, so that the discrepancy would decrease or even resolved. The pros of the surgery include it’s a very minimal invasive procedure; patients usually have very short recovery time. The cons are patients can have lower height than expected; and the candidate for the surgery should have at least 2 years of growth remaining.
For patients who have limited growth potential or have reached maturity, procedures to lengthen the shorter leg can be considered (Figure 1). This is a staged procedure to gradually grow new bone and soft tissues. An extra-skeletal fixator or intramedullary nail would be implanted to the shorter leg and gradually pulled apart at a very slow rate, this a process known as distraction. After bone and soft tissue regenerate and the desired length are obtained, the newly regenerated bone is still very weak. An internal fixation device would replace previous extra-skeletal fixator for the following hardening and calcification of this new bone, which is called the consolidation phase. The exchange of extra-skeletal device to internal fixation will allow you easier daily care and weight bearing as tolerated. The technique is reliable and effective for LLD, even for patients with large discrepancy or severe bone defect. The disadvantages for the procedure include this is a complex and staging surgery, the overall treatment period can range from 3 months to 1 year, and complication rate may be high in inexperienced surgeons.
Genu varum or genu valgum (Bowlegs or X-shaped legs)
・Summary
Genu varum (the so-called bowlegs or O-shaped legs) and genu valgum (also known as knock knees or X-shaped legs) are deformities that can potentially cause knee pain, abnormal gait, functional impairment or even early degenerative arthritis in children. These deformities can be physiologic and resolve as the children grow. However, some patients can have persistent deformity caused by previous skeletal trauma, infection, tumor, growth plate abnormality (ex: Blount disease), genetic disease (ex: achondroplasia) or endocrine disorder (ex: rickets disease).
The first step of approaching genu varum or genu valgum was making the right differential diagnosis and treat the underlying etiology. After pathogenesis of the disease is controlled, surgical intervention will be arranged
・Surgical options
Surgical options depend on the patient’s age and how many skeletal growth remaining. For patients with more than 2 years of growth potential, a minimal invasive surgery known as growth modulation can be considered (Figure 2). Plates or screws would be temporarily implanted to the knee physis to balance the abnormal physeal plate growth. The pros of the surgery include it’s a very minimal invasive procedure; patients usually have very short recovery time. This procedure can also correct limb leg discrepancy at the same time if needed. The cons are patients can have lower height than expected. The deformity may not be fully corrected and require further surgery to achieve this goal.
For patients who have limited growth potential or have reached maturity, one-stage correction can be considered. This involving incompletely cutting the bone (known as osteotomy), leaving the bone hinge intact, realign the lower limb axis and apply rigid fixation at the bone with titanium plate. You are allowed to toe-touch weight bearing with a cane or crutch for 4-6 weeks after the surgery. Rehabilitation program will be applied and then patients are allowed to place all of the weight on the operated extremity 4-6 weeks postoperatively. This procedure can make a significant correction in one surgery even for severe deformity. The disadvantages include the patient cannot immediate fully weight bearing until preliminary bone healing, joint stiffness may develop after a short period of immobilization.
Congenital femoral deficiency
・Summary
Congenital femoral deficiency (CFD) refers to a spectrum of congenital malformations of the thigh bone due to incomplete or abnormal development. It is a rare disease, which occurs in about one in forty thousands births. Severity can range from minor shortening of the femur to complete absence of the femur. Deficiency or instability of the hip and knee joint may also be present. The underlying cause of CFD typically is not known, but it does not appear to be inherited. Taking the drug thalidomide during pregnancy can cause CFD and other limb deficiencies in an unborn child.
- Surgical options
Treatment for CFD can be challenging. Integrated medical team formed by experienced pediatric orthopedic surgeon, pediatrician, rehabilitation specialist and orthotist is required to achieve best outcome. Surgical intervention is usually not emergent, the procedures include limb lengthening for length discrepancy, osteotomy to realign the femur, soft tissue release for contracture and reconstruction of hip and knee joint. A dedicated rehabilitation program is necessary during the course and multiple surgeries are expected for completed treatment.
Congenital pseudoarthrosis of tibia
・Summary
Congenital pseudoarthrosis of the tibia (CPT) refers to nonunion of a tibial fracture that develops spontaneously or after a minor trauma. A pseudoarthrosis is defined as a “false joint” and is a break in the bone that fails to heal on its own. The pseudoarthrosis usually develops within the first two years of life; however, there have been reported cases of CPT development before birth as well as later in life. CPT is a very rare condition, occurring in only 1 out of 250,000 births. The cause of CPT is currently unknown; however, there is a strong association with neurofibromatosis in 50% of cases and an association with fibrous dysplasia in 10% of cases.
・Surgical options
Treatment for CPT can be difficult, the healing potential for the bone is weak and it is frequently refracture even achieve union. Surgical options include meticulously fracture site preparation, augmentation with autologous bone graft (bone will be harvested from your iliac bone to improve biologic environment at fracture site), and rigid fixation with intramedullary rod, plate or extra-skeletal device (Figure 3). CPT can accompany with significant tibial bowing in some cases, which warrant future correction after solid union at pseudoarthrosis site. A coordination team with multiple specialists is required to provide best care.
Tibial/fibular hemimelia
・Summary
Tibial or fibular hemimelia refers to conditions of birth defect where part or all of the tibial or fibular bone is missing. Both disease are rare conditions, the reported incidence rate is 1 in 1 million and 1 in 40,000 for tibial hemimelia and fibular hemimelia, respectively. They can further associate with ankle and foot deformities, limb length discrepancy, and knee deformities, leading to significant functional impairment.
・Surgical options
Surgical treatments for tibial and fibular hemimelia are complicated. The procedure aims at address length discrepancy, osteotomy to correct bowing, soft tissue release for contracture and reconstruction knee and ankle joint. The treatment for tibial or fibular hemimelia can be a very challenging process. Multiple surgeries are expected during the treatment course. Meticulous surgical technique, vigilant follow up, and aggressive rehabilitation are all required for a successful outcome.
Treatment timeframe
・Consultation (Online available)
・Pre-treatment planning
・Explain treatment option, pros and cons, benefits and risks of treatment
・Estimate cost
・Informed consent
・Hospitalization
・Surgery
・Physical Therapy and rehabilitation program
・Follow-up visit
Potential complication
Treatment for lower limb deformities is usually challenging and requires longer treatment duration and follow-up compared to general orthopedic surgery. For these reasons, we are very conservative regarding many aspects of surgical option. The first priority of our care is patient safety and preventing complications. Potential complications are listed below, most of which are reversible and will not cause permanent sequela.
・Wound infection requiring antibiotic treatment or debridement
・Intraoperative bleeding requiring transfusion
・Nerve injury during correction or lengthening
・Nonunion after osteotomy
Estimated cost
For estimated medical costs, please contact International Medical Services Center.