Asymmetric Flexion Contracture is Associated With Leg Length Inequality in Patients With Knee Osteoarthritis: Data From the Osteoarthritis Initiative.

OBJECTIVE: To evaluate whether knee flexion contracture (FC) was associated with leg length inequality (LLI) and/or morbidity in knee osteoarthritis (OA). DESIGN: We accessed 2 databases: (1) the Osteoarthritis Initiative (OAI) cohort, including participants with, or at-risk of OA, and (2) the Ottawa Knee Osteoarthritis cross-sectional database (OKOA), including participants with primary advanced knee OA. Both included demographics, radiographic data, knee range of motion, leg length, pain, and function scales. SETTING: Tertiary care academic rheumatology and orthopedic clinics. PARTICIPANTS: Patients with or at-risk of primary OA. We included 881 OAI and 72 OKOA participants (N=953). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome tested the association between the difference in knee extensions of the OA and contralateral knees (the knee extension difference, or KExD) and LLI. This was evaluated using bivariate regression, followed by a multivariable linear regression model. RESULTS: OAI participants had less severe knee OA [Kellgren and Lawrence (KL) score 1.9±1.3] vs OKOA (KL score 3.4±0.6). The KExD correlated with LLI for both databases (OAI: R=0.167; P≤.001; OKOA: R=0.339; P=.004). Multivariable regression showed an effect of KExD on LLI in both databases (OAI: ß=0.37[0.18,0.57]; P<.001, OKOA: ß=0.73[0.20,1.26]; P=.007). When broken down by subgroup, the OAI moderate-severe OA group showed a significant effect of KExD on LLI (ß=0.60 [0.34,0.85]; P<.001). CONCLUSIONS: OA-related loss of knee extension was associated with LLI for those with moderate-severe OA. Because LLI correlates with worse knee OA symptoms, discovering an FC should cue clinicians to evaluate for LLI, an easily-treatable finding that may help reduce OA-associated morbidity for those approaching the need for arthroplasty.

Induced leg length inequality affects pelvis orientation during upright standing immediately following a sit-to-stand transfer: a pre-post measurement study.

BACKGROUND: Leg length inequality (LLI) greater than 20 mm has been associated with low back pain (LBP) and its correction is clinically recommended. Much less is known about the biomechanical effects that LLI below 15 mm has on pelvis orientation. METHODS: Twenty-two adult participants (8 female) aged between 18 and 30 years without LBP were enrolled in the study and completed a series of sit-to-stand trials with no heel-lift (0 mm baseline) and heel-lifts of varying heights (5, 9 and 12 mm) placed in their right shoe. Three-dimensional kinematic data were obtained from the lower extremities, pelvis and thorax. Additional kinematic data were obtained from the left and right sides of the pelvis. The global orientation of the whole pelvis and relative orientation between the left and right sides of the pelvis were obtained in upright standing immediately upon completion of the sit-to-stand movement. Repeated measures ANOVAs were used to detect differences in sample means across the different levels of heel-lift (0, 5, 9, and 12 mm). The tests for within-subject effects determined overall significant differences between the means at the different levels of heel-lift induced LLI. Partial Eta-Squared was used to express the size for the main effect of heel-lift height. For each level of heel-lift, the estimated marginal mean and 95% confidence interval (95%CI) values of pelvis angles were illustrated graphically. RESULTS: Left frontal plane rotation of the pelvis increased (p = 0.001), that is, the left side of the pelvis was lower than the right side of the pelvis, and anterior tilt of the pelvis decreased (p = 0.020) with a heel-lift height (applied on the right) as low as 5 mm. A significant main effect of heel-lift was only observed for the norm of rotations about all three axes for relative-pelvis orientation (p = 0.034). Post-hoc analyses did not reveal any statistically significant differences between the heel-lifts and the 0 mm baseline (p≥0.072). CONCLUSION: These findings suggest that correcting leg length inequality below the recommended threshold of 20 mm may influence pelvic orientation. Future work can investigate the effects of the altered orientations on spine loading and the clinical effects of corrections to minor leg length inequality.

Indications for Lumbar Fusion in the Skeletally Mature Adolescent: How to Address Oblique Takeoff and Limb Length Discrepancy.

BACKGROUND: Indications for posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) of a scoliotic deformity in a skeletally mature individual are based on the balance between the anticipated benefit of stopping future curve progression and the potential downside of loss of spinal mobility. The dilemma regarding PSF with SSI in the adolescent population is exacerbated by the patient's participation in athletics requiring flexibility and motion of the spine, the location of the curve, the presence of pelvic obliquity, and the impact of a limb length discrepancy. The purpose of this review is to discuss the potential advantages and disadvantages of PSF with SSI in a hypothetical skeletally mature adolescent with a 45-degree lumbar curve, pelvic obliquity, and limb length discrepancy. DISCUSSION: Natural history studies of untreated adolescent idiopathic scoliosis (AIS) have shown that slow curve progression throughout adulthood is likely. Adults with untreated AIS may also have more back pain and dissatisfaction with their appearance. Although the clinical and radiographic outcomes of PSF with SSI are excellent, patients should be counseled about the impact of fusing the lumbar spine on back pain, decreased spinal mobility, and potential inability to return to athletics at the same level. Adults who undergo surgery for AIS have greater operative morbidity and number of levels fused compared with adolescents. CONCLUSION: These factors should be presented when discussing observation versus PSF with SSI with patients and families. Delaying surgery until formal athletic participation is complete should be considered.

Femoral lengthening might impair physical function and lead to structural changes in adjacent joints: 10 patients with 27 to 34 years' follow-up.

Background and purpose - Literature describing long-term functional outcome and osteoarthritis (OA) in adjacent joints after femoral lengthening is rare. We evaluated physical function and the presence of radiographic OA in adjacent joints in 10 patients ≥ 27 years after femoral lengthening.Patients and methods - We conducted a cross-sectional study of 10 patients treated by unilateral femoral lengthening. Follow-up was between 27 and 34 years. Physical function was evaluated by the 30-second sit-to-stand (30sSTS) and a stair test and was compared with reference values. 4 single-legged hop tests were used to assess difference in physical function between the lengthened and contralateral limb. Radiographic OA was evaluated by joint space width (JSW) and Kellgren and Lawrence (KL) classification.Results - The patients scored worse compared with reference values on the 30sSTS and stair test, and worse on the lengthened limb on the single- and triple-hop test. Radiographic OA was found in the hip or knee in the lengthened limb in 3 of 10 patients based on JSW and 4 of 10 based on KL. No radiographic OA was found in unlengthened limbs.Interpretation - Our results showed impaired physical function both in general and of the lengthened limb. Additionally, we found a possible association between femoral lengthening and radiographic OA in adjacent joints in the long term. However, the sample size of the current study is small.

Correction of leg-length discrepancy among meat cutters with low back pain: a randomized controlled trial.

BACKGROUND: The etiology of non-specific low back pain (LBP) is complex and not well understood. LBP is common and causes a remarkable health burden worldwide. Leg-length discrepancy (LLD) is potentially a risk factor for development of LBP, although this relationship has been questioned. Yet only one randomized controlled study (RCT) has been performed. The objective of our study was to evaluate the effect of insoles with leg-length discrepancy (LLD) correction compared to insoles without LLD correction among meat cutters in a RCT-design. METHODS: The study population consisted 387 meat cutters who were over 35 years old and had been working 10 years or more. The LLD measurement was done by a laser ultrasound technique. All workers with an LLD of at least 5 mm and an LBP intensity of at least 2 on a 10-cm Visual Analog Scale were eligible. The LLD of all the participants in the intervention group was corrected 70%, which means that if the LLD was for example 10 mm the correction was 7 mm. The insoles were used at work for eight hours per day. The control group had insoles without LLD correction. The primary outcome was between-group difference in LBP intensity. Secondary outcomes included sciatic pain intensity, disability (Roland Morris), RAND-36, the Oswestry Disability Index, physician visits and days on sick leave over the first year. We used a repeated measures regression analysis with adjustments for age, gender and BMI. The hurdle model was used for days on sick leave. RESULTS: In all, 169 workers were invited and 114 (67%) responded. Of them, 42 were eligible and were randomized to the intervention (n = 20) or control group (n = 22). The workers in the intervention group had a higher improvement in LBP intensity (- 2.6; 95% confidence intervals - 3.7 - - 1.4), intensity of sciatic pain (- 2.3; - 3.4 - - 1.07) and RAND-36 physical functioning (9.6; 1.6-17.6) and a lesser likelihood of sick leaves (OR -3.7; - 7.2 - -0.2). CONCLUSIONS: Correction of LLD with insoles was an effective intervention among workers with LBP and a standing job. TRIAL REGISTRATION: ISRCTN11898558 . Registration date 11. Feb 2011. BioMed Central Ltd.

Leg Length Discrepancy: The Natural History (And What Do We Really Know).

BACKGROUND: The long-term effects of small limb length discrepancies have been poorly documented in the literature. References to low back pain, hip pathology, knee pathology, and foot problems abound in the popular literature. Health care providers frequently recommend the use of lifts for structural and functional limb length discrepancies, yet the natural history of limb length inequality as well as the effectiveness of treatments that may be recommended are obscure. The purpose of this paper is to document and evaluate the literature associated with small limb length discrepancies. METHODS: A search of the English literature was carried out using PubMed to identify papers dealing with the effects of limb length discrepancies. Papers reporting only expert opinion or case reports were excluded. RESULTS: Papers dealing with the natural history of limb length discrepancy as well as studies in which gait analysis was performed in patients with limb length discrepancy were identified. Only 10% of the population has exactly equal lower limb lengths. Approximately 90% of the population has a limb length discrepancy <1.0 cm. Hip and knee pathology is present in an increased number of patients with limb length discrepancies over 5 mm. Hip pathology is more often present in the long leg, knee pathology has been reported in various studies to be more common in either the long or short leg. Low back problems seem to be more common on the short side in patients with limb length discrepancies. A number of different compensatory mechanisms for limb length discrepancy have been identified during gait analysis. CONCLUSIONS: There seems to be a consensus that limb length discrepancies >2.0 cm are frequently a problem. There is some evidence that limb length discrepancies as little as 5 mm can lead to long-term pathology.

Shoe Lifts for Leg Length Discrepancy in Adults With Common Painful Musculoskeletal Conditions: A Systematic Review of the Literature.

OBJECTIVE: To determine whether shoe lifts effectively treat leg length discrepancy (LLD)-associated morbidities in adults with common painful musculoskeletal conditions. DATA SOURCES: Trip database, Cochrane Central Register of Controlled Trials database, PubMed database, Physiotherapy Evidence Database, and National Guideline Clearinghouse database. The search was performed in September 2017, was limited to English only, and had no time constraints. STUDY SELECTION: Two reviewers independently determined study eligibility. Inclusion criteria were (1) participants ≥18 years old with musculoskeletal-related complaints and LLD; (2) a shoe lift intervention was used; and (3) the study reported on pain, function, range of motion, patient satisfaction, quality of life, or adverse events. Randomized controlled trials (RCTs) and controlled intervention, cohort, before-and-after, case series, and case report studies were included. Three-hundred and nineteen articles were screened, and 9 guidelines were reviewed. DATA EXTRACTION: We extracted data pertaining to participant demographic characteristics, study setting, recruitment, randomization, method of LLD measurement, shoe lift characteristics, treatment duration, and outcome measures. We included 10 studies, including 1 RCT. DATA SYNTHESIS: LLD was associated with low back pain, scoliosis, and osteoarthritis of the hip and knee. Description of LLD correction strategy was often inadequate. Study quality was very low or poor. In non-RCT studies reporting on the proportion of participants who improved with a shoe lift, 88%±3% of 349 participants treated had partial or complete pain relief (effect size range, 66.7%-100%). All 22 RCT participants receiving treatment experienced pain relief (mean pain reduction, 27±9mm on a 150-mm visual analog scale). Two of 9 guidelines recommended shoe lift use based on consensus and were of moderate-to-high quality. CONCLUSIONS: There is low-quality evidence that shoe lifts reduce pain and improve function in patients with LLD and common painful musculoskeletal conditions. High-quality research evaluating a threshold LLD to correct and a strategy to do so is necessary. Developing an appropriate comparison group to test clinically relevant outcome measures would make a valuable contribution in this regard.

Utilizing Dual Mobility Components for First-Time Revision Total Hip Arthroplasty for Instability.

BACKGROUND: Dislocation following total hip arthroplasty (THA) remains a significant clinical problem. Few studies have focused on the use of dual mobility (DM) components in the setting of first-time revision for instability following THA. Here, we investigate patient outcomes following first-time revision THA with DM components for a diagnosis of instability. METHODS: Institution-wide revision THAs using DM components performed between 2010 and 2013 were identified. Chart review identified 40 patients with average 3-year follow-up who had undergone first-time revision for instability, defined as instability after primary THA. Etiology of instability was classified by Wera type. Patient demographics, medical co-morbidities, re-dislocations, and re-revisions were recorded. Component position and leg-length discrepancy were measured on pre-operative and post-operative radiographs when available. Utilizing Student's t-test or Fisher's exact test, we analyzed differences between those who endured recurrent dislocation and those who did not. RESULTS: Recurrent dislocation occurred in 2 patients (5%). Both patients underwent re-revision for recurrent instability and carried diagnoses of instability of unresolved etiology. Two patients underwent re-revision for reasons unrelated to the DM construct. All-cause re-revision rate at final follow-up was therefore 10% (4 patients). No medical, demographic, or radiographic factors were significantly associated with risk of recurrent instability (P > .05). CONCLUSION: The use of DM components for first-time revision THA for a diagnosis of instability carried a re-dislocation rate of 5% and an all-cause re-revision rate of 10% at average 3-year follow-up. Instability of unresolved etiology was associated with re-dislocation following revision surgery.

Gait Analysis of Leg Length Discrepancy-Differentiated Hip Replacement Patients With Developmental Dysplasia: A Midterm Follow-Up.

BACKGROUND: Few studies investigate gait characteristics and symmetry of developmental dysplasia of the hip patients (Crowe II and III) after total hip arthroplasty (THA) whose leg length discrepancy (LLD) is within 20 mm. Our study aimed to explore whether gait analysis parameters in these patients can return to the level of unaffected people and how bodies compensate for the discrepancy. METHOD: A total of 45 patients who underwent cementless THA and 20 healthy controls were involved in this study prospectively. Group 1 includes patients whose LLD is <10 mm and group 2 includes patients whose LLD is 10-20 mm. Gait analysis was performed during 5-year midterm postoperative follow-up. RESULT: The parameters, particularly the range of motion (ROM) in the hip, in both experimental groups (1 and 2) were significantly lower than healthy control group. For the nonoperated side, group 1 displayed significantly reduced ROM in the hip and knee compared with the age-matched controls. This was not observed in group 2. Greater bilateral symmetry can be seen in group 1 compared with group 2. CONCLUSION: Despite LLD being limited to within 20 mm, THA patients in both groups showed a less efficient gait than that of healthy controls on 5-year midterm follow-up. The increased ROM in the nonoperated hip may act as a compensatory mechanism. LLD of 10 mm may be a cutoff value to assess whether compensation occurs in the contralateral limb. Reconstruction of equal limb length is recommended when surgeons perform THA for dysplastic hips.

Incidence of knee height asymmetry in a paediatric population of corrected leg length discrepancy: a retrospective chart review study.

PURPOSE: The purpose of the study is to provide a methodology to quantify knee height asymmetry (KHA) and to establish the incidence of knee height asymmetry in a patient population visiting the limb length discrepancy clinic in a paediatric-orthopaedic hospital centre. METHOD: A retrospective chart review was performed on all patients who attended the limb length discrepancy clinic and underwent corrective surgery at the Shriners Hospital for Children-Canada from December 2009 to December 2015. Full-standing anteroposterior radiographs were used to measure pre- and post-surgery limb length discrepancy and knee height asymmetry for 52 individuals included in the study. RESULTS: Sixty-seven percent of the studied population had a KHA of 20 mm or less, 25% had a KHA between 20 and 40 mm, and 8% had a KHA of over 40 mm. The average KHA preoperatively for all 52 individuals was 17 ± 14 mm (range 0-59 mm), which represents roughly 2.5% of total limb length. There was a 3-mm non-significant reduction in KHA size between pre-and post-operative states (p = 0.22). CONCLUSION: The current study provides a method to quantify knee height asymmetry. Using this method, it was shown that knee height asymmetry is frequent in youth with limb length discrepancy in both pre- and post-corrective surgery states. The relatively high incidence of knee height asymmetry highlights the importance to investigate the impact of knee height asymmetry in youth living with a limb length discrepancy.

Avascular Necrosis in the Contralateral Hip in Patients With Congenital Femoral Deficiency: A Report of 3 Cases.

BACKGROUND: Congenital femoral deficiency is an uncommon clinical entity. We report 3 patients who developed avascular necrosis of the hip in the long (normal) leg during longitudinal observation and/or treatment of congenital femoral deficiency. METHODS: Patients were identified in limb length discrepancy clinic and their charts were retrospectively reviewed for clinical and radiographic data collection. RESULTS: We describe the occurrence of idiopathic avascular necrosis in the normal limb in patients being followed for limb length discrepancy. CONCLUSIONS: Although no conclusion could be drawn about the etiology of the avascular necrosis, we describe a previously undocumented relationship between congenital femoral deficiency and avascular necrosis in the contralateral hip. This occurred in our congenital femoral deficiency population at a rate higher than expected compared with published incidences of avascular necrosis of the hip in children. LEVEL OF EVIDENCE: Level IV-case series.

Association of Mild Leg Length Discrepancy and Degenerative Changes in the Hip Joint and Lumbar Spine.

OBJECTIVE: The purpose of this study was to evaluate the correlation between mild leg length discrepancy (LLD) and degenerative joint disease (DJD) or osteoarthritis. METHODS: We evaluated standard postural lumbopelvic radiographs from 255 adults (121 women and 134 men) who had presented with spinal pain for chiropractic care. Symmetry of femoral head diameters was used to exclude magnification errors. Pearson's partial correlation was used to control for age and derive effect sizes for LLD on DJD in the hip and lower lumbar motion segments. Krippendorff's α was used for intraobserver and interobserver reliability. RESULTS: A strong correlation was found between LLD and hip DJD in men (r = 0.532) and women (r = 0.246). We also found a strong correlation between LLD and DJD at the L5-S1 motion segment in men (r = 0.395) and women (r = 0.246). At the L4-5 spinal level this correlation was much attenuated in men (r = 0.229) and women (r = 0.166). CONCLUSIONS: These findings suggest an association between LLD and hip and lumbar DJD. Cause-effect relationships between mild LLD and DJD deserve to be properly evaluated in future longitudinal cohort studies.

Is a long leg a risk for hip or knee osteoarthritis?

Background and purpose - 7% of the asymptomatic population has leg-length inequality (LLI) greater than 12 mm. It has been proposed that LLI of >5 mm can be associated with an increased risk of osteoarthritis (OA) of the knee and hip. We studied a possible association between LLI and OA of the knee and hip joint. Patients and methods - We followed 193 individuals (97 women, 96 men) for 29 years. The initial mean age of the participants was 43 (34-54) years, and they had no clinical histories or signs of leg symptoms. The initial standing radiographs of their hips were re-examined and measured for LLI and signs of OA. None had any signs of OA. At the follow-up, data on performed hip or knee arthroplasties were obtained. Results - 24 (12%) of the subjects had no discernible leg-length difference, 62 (32%), had LLIs of 1-4 mm, 74 (38%) of 5-8 mm, 21 (11%) of 9-12 mm, and 12 (6%) of over 12 mm. 16 (8%) of the subjects had undergone arthroplasty for primary OA during follow-up, and of those, 8 for both hip and knee OA. 10 individuals had undergone an arthroplasty of the longer leg and only 3 of the shorter leg. In the group of equal leg length, 3 had had an arthroplasty of hip or knee. Interpretation - We noted that hip or knee arthroplasty due to primary OA had been done 3 times more often to the longer leg than to the shorter.

Deconstructing Chronic Low Back Pain in the Older Adult-Step-by-Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XII: Leg Length Discrepancy.

OBJECTIVE: To present the last in a 12-part series designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on leg length discrepancy (LLD) and presents an algorithm outlining approaches to diagnosis and management of LLD in older adults, along with a representative clinical case. METHODS : Using a modified Delphi approach, the LLD evaluation and treatment algorithm was developed by a multidisciplinary expert panel representing expertise in physical therapy, geriatric medicine, and physical medicine and rehabilitation. The materials were subsequently refined through an iterative process of input from a primary care provider panel comprised of VA and non-VA providers. The clinical case was taken from one of the authors. RESULTS : We present an algorithm and illustrative clinical case to help guide the care of older adults with LLD, which can be an important contributor to CLBP. Firstline assessment includes referral to physical therapy or orthopedics, depending on the context of the LLD. A variety of nonsurgical interventions may ensue depending on the etiology of the LLD, including shoe inserts, customized shoes, manual therapy, or a combination. CONCLUSIONS : To promote a patient-centered approach, providers should consider evaluating for leg length discrepancy when treating older adults with CLBP to help diminish pain and disability.

The effect of leg length discrepancy on clinical outcome after TKA and identification of possible risk factors.

PURPOSE: This study was investigated on the leg length discrepancy (LLD) after computer-assisted total knee arthroplasty (TKA), and its effects on the post-operative function and patient satisfaction. It is hypothesized that LLD after computer-assisted TKA would affect the clinical outcomes for knee scores. METHODS: A total of 148 cases were analysed retrospectively with a minimum of 2 years of follow-up. Eighty-one knees involved a <15-mm LLD, and 67 knees involved more than a 15-mm LLD. The radiographic outcomes, clinical outcomes, patients' satisfaction, and perception of LLD were also evaluated. RESULTS: There was a significant difference in the Knee Society function score and the score for the difficulty with ascending the stairs in the Western Ontario and McMaster Universities score between the groups. There was a statistically significant difference between the two groups in the results of their perception questionnaires, but no difference in the results of their satisfaction questionnaires. The odds ratio for the risk of post-operative LLD increased with the increased pre-operative LLD and the unilateral TKA. CONCLUSIONS: In conclusion, the functional outcomes of more than 15-mm post-operative LLD after computer-assisted TKA were lower than those of the <15-mm LLD. Thus, the reduced post-operative LLD should be considered to improve the functional outcomes of primary TKA. A careful treatment plan for degenerative arthritis should be considered and discussed with patients, especially in unilateral TKAs. LEVEL OF EVIDENCE: IV.

Effect of Preoperative Leg Length Discrepancy on Functional Outcome and Patient Satisfaction After Total Hip Arthroplasty in Cases of Osteonecrosis of the Femoral Head.

BACKGROUND: Severe preoperative leg length discrepancy (LLD) can lead to poor preoperative functional status in patients with extensive osteonecrosis of the femoral head (ONFH). This study aimed to assess the effect of preoperative LLD on functional outcomes and patient satisfaction post-total hip arthroplasty (THA) in ONFH patients. METHODS: Twenty-two patients with severe LLD (≥15 mm) and 44 patients with mild LLD (<15 mm) on preoperative radiographs were enrolled as the study group and control group, respectively. All 66 patients were diagnosed with unilateral ONFH. Patients' functional outcomes (Harris Hip Score [HHS], Oxford Hip Score [OHS], patient-perceived LLD, Visual Analogue Scale [VAS] pain score, and Limping Assessment]) and satisfaction (self-administered patient satisfaction scale) were evaluated at 3 and 12 months after THA. RESULTS: At 3 months after THA, the study group had poorer outcomes in terms of the HHS (P = .002) and OHS (P = .002), a higher prevalence of patient-perceived LLD (P = .002), and worse limping (P < .001) than the control group, but the self-administered patient satisfaction scale and VAS pain scores did not differ. However, improvements in the HHS and OHS from preoperative assessment to 3 months were comparable in both groups. At 12 months after THA, there were no significant differences in functional outcomes or self-satisfaction, and the study group showed significantly greater improvements from preoperative assessment to 12 months (P < .05). CONCLUSION: Patients with severe LLD experienced similar improvement at 3 months after THA as those with mild LLD in terms of the HHS and OHS but showed greater improvement at 12 months postoperatively than patients with mild LLD.

Leg-length discrepancy is associated with low back pain among those who must stand while working.

BACKGROUND: Some studies suggest that leg length discrepancy (LLD) is associated with low back pain (LBP) but many have not found such an association leading to conflicting evidence on the role of LLD in LBP. METHODS: The study population consisted of meat cutters with a standing job and customer service workers with a sedentary job from Atria Suomi Ltd (Nurmo, Finland) who were at least 35 years old and had been working in their jobs for at least 10 years. Leg length of each participant was measured with a laser range meter fixed in a rod, which was holding the scanning head of the ultrasound apparatus. Association of the intensity of LBP (10-cm Visual Analog Scale) with LLD was analysed by linear regression model, while the hurdle model was used in analysing the association of number of days with LBP and days on sick leave during the past year. Associations were adjusted by gender, age, BMI, smoking, depressive feelings and type of work (standing or sedentary job). RESULTS: The final study population consisted of 114 meat cutters (26 females and 88 males) and 34 customer service workers (30 females and four males). Forty-nine percent of the meat cutters and 44% of the customer service workers had LLD of at least 6 mm, while 16% and 15%, respectively, had LLD of at least 11 mm. In the whole study population, LLD of 6 mm or more was associated with higher intensity of LBP and number of days with LBP. In the stratified analysis, both intensity of LBP and number of days of LBP were associated with LLD among meat cutters but not among customer service workers. The sick leaves during past year were slightly longer among those with LLD 10 mm or more, but the differences were not statistically significant. CONCLUSIONS: LLD, measured with a laser range meter, was associated with intensity of LBP and self-reported days with LBP during the past year among meat cutters engaged in standing work. TRIAL REGISTRATION: ISRCTN11898558--The role of leg length discrepancy in low back pain.

Atlas orthogonal chiropractic management of trigeminal neuralgia: A series of case reports.

CONTEXT: Trigeminal neuralgia is a debilitating facial pain condition. Upper cervical chiropractic care has been mentioned as a possible solution OBJECTIVE: To determine the effects of Atlas Orthogonal upper cervical chiropractic technique adjustments on trigeminal neuralgia sufferers DESIGN: Case series SETTING: A private chiropractic practice PARTICIPANTS: Five persons with chronic, severe, daily trigeminal neuralgia pain, radiological findings of significant head tilt, pain upon upper cervical palpation, and supine leg length inequality INTERVENTIONS: Up to two consultations and/or Atlas Orthogonal adjustments a week for eight weeks OUTCOME MEASURES: Self-reported reduction in trigeminal neuralgia pain and changes in radiological findings, sensitivity to upper cervical palpation, and leg length inequality RESULTS: Four participants reported reduced trigeminal neuralgia pain, including two with complete cessation of pain. Three participants reduced medication dosages. One reported no change.

Determination of the amount of leg length inequality that alters spinal posture in healthy subjects using rasterstereography.

PURPOSE: Leg length inequalities (LLIs) can result in an increased energy consumption, abnormal gait or osteoarthritis of the hip. In a previous study we simulated different LLIs of up to 15 mm and evaluated their effects on the pelvic position and spinal posture. We found a correlation between LLIs and resulting changes of the pelvic position. Despite suggestions in the literature we were not able to detect significant changes of the spinal posture. Therefore, the purpose of this study was to determine the amount of LLI that would in fact alter the spinal posture. METHODS: The subjects were placed on a simulation platform, whose height could be precisely controlled by the measuring device, to simulate different LLIs of up to 20 mm. For LLIs >20 mm, additional precision-cut wooden blocks were used under one foot. After an adaptation period the resulting changes of the pelvis and spine were measured with a rasterstereographic device. RESULTS: We found a significant correlation between platform height changes and changes of the pelvic position. The frontal spinal parameters surface rotation and lateral deviation changed significantly when simulating differences greater than 20 mm. No changes of the sagittal spinal curvature were measured, however, a trend to decreasing kyphotic angles was noted. CONCLUSIONS: Our study has shown for the first time that LLIs >20 mm will lead to significant changes in the spinal posture of healthy test subjects. However, these changes were only found in frontal (surface rotation and lateral flexion) spinal parameters, but not in sagittal parameters. Here for the kyphotic angle only a tendency to decreasing angles was noted. We have also found a significant correlation between different leg lengths and changes of the pelvic position. Further, females and males seem to react in the same way to LLIs.

[Treatment of external fixator in young patients with valgus deformity of the knee companied with leg shortening].

OBJECTIVE: To explore the efficacy and experience of callus distraction technique with the external fixator for valgus deformity of the knee companied with leg shortening in young patients and to provide evidence for selecting reasonable therapy. METHODS: From January 2002 to January 2009, the clinical data of 28 young patients (17 males and 11 females, aged 8 to 14, mean age 11.9 years) treated with callus distraction, who had valgus deformity of the knee, companied with leg shortening, were analyzed retrospectively. Three had bilateral total valgus deformity of the knee, with a total of 31 knees. Before the operation, the abnormal limbs shortened from 3 to 7 cm (average 4.1 cm) companied with the normal one. The tibiofemoral angle ranged from 138° to 160° (mean angle 148°) and the Condyle interval from 5 to 33 cm (mean interval 15.2 cm). RESULTS: The 28 patients were followed up for 35 to 84 ( mean 62 ) months. The extent length ranged from 4.5 to 10.1 cm (average 6.8 cm). The tibiofemoral angle ranged from 169° to 175° (mean 173°) after the union. The patients resumed the normal length of limbs, and the severe valgus deformity of the knee was corrected. CONCLUSION: Callus distraction with external fixator is effective for serious valgus deformity of the knee companied with leg shortening.