Management of Leg Length Inequality

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


J South Orthop Assoc. 2001;10(2) 

In This Article


Numerous complications of limb lengthenings occur frequently, even in experienced hands. Complication rates vary significantly from reported studies and seem to depend on degree of lengthening, definition of complication, and the surgeon's experience.[65] Complication rates from most series, including ours, are about one per procedure, and many of these require operative treatment.[51,57,66] Fortunately, the ultimate objective often can still be obtained. The most common complication is pin site infection. Depending on how it is diagnosed, treated, and reported, this complication may occur in nearly every patient. Numerous pin care protocols have been developed. Some authors are showing good success with a shower regimen after the incisions have healed. We use this in combination with standard cleaning of the pin sites and oral antibiotics if there is excessive discharge, redness, or swelling. Most patients have periosteal reaction around the pin sites, which may be an early indication of loosening.[67]

In femoral lengthenings, knee range of motion uniformly decreases by an average of 37°, but at follow-up the mean loss in range of motion is usually minimal.[68] Other more ominous complications include fracture, osteomyelitis, or joint subluxation. The incidence of these more serious complications is about 25% with an experienced surgeon.[65]

Other less commonly considered effects of limb lengthening include muscle weakness,[69,70] pain, and possible physeal inhibition. The later effect is extremely important if lengthenings are planned for younger patients with open physis. Hope et al[71] found little difference in growth velocities before and after lengthening, but Viehweger et al[72] found growth inhibition in the tibia after lengthenings in children. Review of our patients has shown no significant decrease in the rate of growth after lengthening, though these have largely been femoral lengthenings. Unlike pain associated with conventional surgery, pain due to lengthening seems to continue beyond the postoperative period and through the lengthening and consolidation phases,[73] until the fixator is removed.

The use of somatosensory evoked potential monitoring may be helpful in preventing neurologic injuries, especially of the peroneal nerve.[74] The use of ultrasound and/or electrical stimulation, while not routinely prescribed, may decrease the time to consolidation.[75]


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