Management of Leg Length Inequality

James J. McCarthy, MD, and G. Dean MacEwen, MD


J South Orthop Assoc. 2001;10(2) 

In This Article

Abstract and Introduction


Leg length inequality is common. Treatment objectives include obtaining leg length equality, producing a level pelvis, and improving function. Clinical assessment should include determination of a level pelvis with the patient standing using a set of blocks of various heights to estimate the amount of leg length inequality. Radiographic measures include the teleroentgenogram, orthoradiograph, and computed tomography (CT). A prediction of the ultimate leg length inequality at skeletal maturity will be needed to determine treatment. Our guidelines for treatment of leg length inequality are as follows: <2 cm -- no treatment or a lift in the shoe; 2 to 6 cm -- an epiphysiodesis or shortening procedure is considered; 6 to 15 cm -- a lengthening procedure is considered. A leg length inequality of 15 to 20 cm -- may require a staged lengthening, lengthening combined with epiphysiodesis, or amputation. Numerous complications of limb lengthening procedures occur frequently, even in experienced hands.

Leg length inequality is common, 23% of the general population having a discrepancy of 1 cm or more.[1] The prevalence of leg length inequality requiring a corrective device, such as a lift, is approximately 1 in 1,000.[2] In this review, we discuss the etiology, functional effects, assessment, and treatment of leg length inequality.

The first published report of lengthening was by Codivilla[3] in 1905. He achieved lengthening by incremental maximal lengthening under anesthesia. There were numerous problems with stabilization of the fragments as well as the sequelae of sudden large lengthenings, including sudden death. In 1939, Abbott and Saunders[4] reported on their lengthening procedure using external fixation and incremental distraction, much as we do today with a monolateral fixator. Wagner[5] developed a technique of open lengthening, in which the tibia or femur was divided and rapid lengthening was done until the desired length was achieved. The distraction gap was then bone grafted and plated. Although originally popular, this technique fell out of favor because of the need for multiple operations (at least three, including plate removal) and the extremely high rate of complications.

The Ilizarov technique and variations thereof are used most often today.[6] The procedure is named after Gavril Abramovich Ilizarov, a Russian physician who first used his technique to treat injured World War II veterans. Lengthening is usually done by corticotomy and gradual distraction with a ring fixator and fine wires.


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