Critical review of the classification and treatment of pediatric pelvic fractures.

BACKGROUND: Historically most pediatric pelvic fractures were treated non-operatively because of the presumed potential of the pediatric pelvis to remodel and the subsequent increased fracture stability. Currently a wide variety of classifications in pediatric pelvic fractures is used to assess fracture stability and guide treatment, yet none have proven to be ideal since the structural behavior of the pediatric pelvis differs greatly from the adult pelvis. The aim of this review is to critically appraise the use of these different classification systems, fracture (in)stability, the treatment of pediatric pelvic fractures and how it reflects on long-term complications such as pelvic asymmetry and functional outcome. METHODS: A literature search was performed in Medline, Embase, Cochrane, PubMed, Google Scholar and references of the selected articles. Studies that reported on pain, leg length discrepancy (LLD), abnormal gait (GA), pelvic asymmetry, and functional outcomes of pediatric pelvic fractures were included. RESULTS: A total of six different classification systems were used, the most common were Tile (n= 9, 45%) and Torode and Zieg (n= 8, 40%). There was great disparity in treatment choice for the same type of fracture pattern, resulting in several pelvic ring fractures that were defined as unstable being treated non-operatively. Pelvic asymmetry is seen in rates up to 48% in non-operatively treated patients. In contrast, pelvic asymmetry in surgically fixated unstable pelvic fractures was rare, and these patients often showed excellent functional outcomes during follow-up. CONCLUSION: There is a substantial heterogeneity in which fracture patterns are considered to be unstable or in need of surgical fixation. Functional outcomes seem to be correlated with the frequency of pelvic asymmetry and are likely due to an underestimation of the stability of the pelvic fracture. Taking into consideration the force that is necessary to cause a facture in the pediatric pelvis, a fracture of the pelvic ring alone could be suggestive for instability. The results of this review imply that the field of pediatric pelvic surgery is currently not grasping the full scope of the complexity of these fractures, and that there is a need for a pediatric pelvic classification system and evidence-based treatment guideline.

Proximal Femoral Focal Deficiency/Congenital Femoral Deficiency: Evaluation and Management.

Proximal focal femoral deficiency is a congenital transverse deficiency in which the femur is globally smaller with a typical proximal deformity at the hip that may include distal involvement of knees, leg, and feet. Congenital femoral deficiency (CFD) describes a broader spectrum of longitudinal deficiency inclusive of proximal focal femoral deficiency. CFD may also include lateral distal femoral hypoplasia, knee cruciate ligament deficiency, rotational instability, patellar dislocation, fibular hemimelia, ray absence, and contralateral limb involvement. Treatment intends to maximize function by limb equalization and deformity correction ranging from nonsurgical management using prosthetics to amputation and may include lengthening, shortening, and complex limb reconstruction. Management decisions depend on overall severity and the patient and family's preferences and priorities. Owing to its complexity, CFD is best treated by clinicians with considerable deformity treatment experience who can help guide decision making and embark on a treatment course that will maximize the functional outcome.

Effect of correction of leg length discrepancy on the biomechanical characteristics of the pelvis and hip joints among standing workers.

BACKGROUND: Few studies have reported the contribution of correction of leg length discrepancy (LLD) on the kinematic and kinetic characteristics of the pelvis and hip joints among those who must stand while working using shoe insoles and a three-dimensional (3D) motion analysis system. OBJECTIVE: To investigate dynamic pelvic and hip joint angles and hip moments using a 3D motion analysis system with and without insoles in standing workers with LLD. METHODS: Kinematic and kinetic data of 31 participants with LLD were collected using a motion analysis system and force platforms. Participants were asked to walk wearing standard shoes or shoes with LLD-corrected insoles. Repeated-measures analysis of variance (ANOVA) was used to compare the kinematic and kinetic data of the hip joints and pelvic orientation according to leg side and corrective interventions for LLD. RESULTS: There were significant differences in maximal ROM of hip adduction and abduction with vs. without LLD insoles in the longer and shorter legs (p < 0.05). There were significant differences in maximal elevation (p = 0.004) and total coronal motion (p = 0.006) of the pelvic segment with and without insole corrections in the longer leg during gait. CONCLUSIONS: LLD correction using a customized insole is a recommended therapeutic intervention to improve the musculoskeletal imbalances of hip and pelvic segments in workers with LLD.

Effects of orthotic insole on gait patterns in children with mild leg length discrepancy.

BACKGROUND: Leg length discrepancy (LLD) is commonly associated with compensatory gait strategies leading to musculoskeletal disorders of the lower extremity and lumbar spine. Orthotic insole (OI) is considered as a conservative treatment for patients with mild LLD, especially for children. However, the restoration of normal gait when wearing OI with foot lift are still poorly understood. RESEARCH QUESTION: What are the immediate effects of OI on the gait patterns in children with mild LLD? METHODS: Gait data and plantar pressure data were collected for 12 children with mild anatomical LLD in barefoot and OI conditions. Paired t-test was performed to determine the changes in gait between these two conditions, and also the symmetry between limbs in the same condition for spatiotemporal, kinematic, and kinetic variables. RESULTS: Children with mild LLD showed an immediate gait improvement confirmed by increased step length and velocity, decreased peak plantar pressure in both limbs with OI. Additionally, the significant between-limb differences disappeared for peak ankle dorsiflexion, hip adduction, pelvis upward obliquity and also second peak plantar pressure with OI, which improved gait symmetry. SIGNIFICANCE: This study provides a better understanding of the immediate effect of OI with foot lift on biomechanical changes in gait, which identify that OI with foot lift could be a potential therapeutic option for children with mild structural LLD to improve gait metrics.

Overview and Spinal Implications of Leg Length Discrepancy: Narrative Review.

Leg length discrepancy (LLD) is an underrecognized and prevalent condition among the U.S. population, with effects varying depending on the cause and size of the discrepancy. LLD occurs when the paired lower extremities are unequal in length and can be etiologically classified as functional or structural. Length differences are typically less than 10 mm and asymptomatic or easily compensated for by the patient through self-lengthening or shortening of the lower extremities. Literature review of the etiology, diagnostic modalities, clinical complications, and treatment option for patients with LLD. LLD can be assessed directly through tape measurements or indirectly through palpation of bony landmarks. Imaging modalities, specifically radiography, are more precise and help identify coexistent deformity. Once LLD has been diagnosed, evaluation for potential adverse complications is necessary. Discrepancies greater than 20 mm can alter biomechanics and loading patterns with resultant functional limitations and musculoskeletal disorders, such as functional scoliosis. Functional scoliosis is nonprogressive and involves a structurally normal spine with an apparent lateral curvature, which regresses fully or partially when the LLD is corrected. Long-standing LLD and functional scoliosis often result in permanent degenerative changes in the facet joints and intervertebral discs of the spine. Further understanding of the contribution of LLD in the development of scoliosis and degenerative spine disease will allow for more effective preventative treatment strategies and hasten return to function.

Sistema de clavo endomedular motorizado Precice® en discrepancia de longitud de miembros / Precice® Motorized Endomedullary Nail System in Limb Length Discrepancy

CONTEXTO CLÍNICO: La discrepancia en la longitud de las extremidades se define como la diferencia entre las longitudes de los brazos o las piernas. Estudios epidemiológicos estiman que aproximadamente el 90% de la población tiene una discrepancia en la longitud de las extremidades <1,0 cm.1 Se han identificado varios mecanismos compensatorios para atenuar esta discrepancia durante el análisis de la marcha, sin embargo cuando la diferencia en la longitud de las extremidades es > 2,0 cm, necesitan tratarse dado que la sobrecarga esquelética y mecanismos compensadores pueden ser finalmente perjudiciales. Las causas de discrepancia de longitud pueden afectar a pacientes de cualquier edad y en la población pediátrica puede ser congénita o adquirida. Algunas causas de discrepancia congénita son las malformaciones como hemimelia peronea, hemimelia tibial, deficiencia femoral congénita, hemihipertrofia u otras hipoplasias de extremidades. Las causas adquiridas de la infancia, generalmente se deben a una lesión en el cartílago de crecimiento por trauma, infección, radiación o tumor. En los adultos, las causas más frecuentes son secundarias a fracturas de los huesos largos con pseudoartrosis u osteomielitis con resección de tejido óseo. El tratamiento de la discrepancia en la longitud de los miembros inferiores se trata mediante el uso de correcciones del calzado, y en el caso de los pacientes pediátricos, cirugías del cartílago de crecimiento contralateral de acortamiento cuando la diferencia es entre dos y seis centímetros.4 En caso de discrepancias de seis a 20 cm, se indica realizar un alargamiento óseo. TECNOLOGÍA: El clavo endomedular para alargamiento Precice® (NuVasive Inc.) es un clavo telescópico operado por fuerza magnética que mediante dos magnetos rotatorios externos, que el paciente se coloca sobre la piel y a través de un control remoto, activa un sistema que puede elongar o comprimir la longitud del clavo telescópico. La longitud máxima de elongación es de ocho cm aproximadamente. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso del clavo endomedular motorizado Precice® para alargamiento óseo en pacientes con discrepancia en la longitud de los miembros inferiores. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso del clavo endomedular motorizado Precice® para alargamiento óseo en pacientes con discrepancia en la longitud de los miembros inferiores. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: No se encontraron estudios prospectivos aleatorizados que comparen el uso del sistema Precice® con otros sistemas de alargamiento óseo o con otro tratamiento no quirúrgico. Se incluyeron cinco estudios retrospectivos comparativos, una revisiones sistemática, tres series de casos, una recomendación de sociedad científica y una de grupo de expertos, una evaluación económica y una evaluación de tecnología sanitaria, una guía de procedimientos y 10 informes de políticas de cobertura acerca del uso del sistema de clavo endomedular motorizado Precice® para elongación ósea en discrepancia de miembros inferiores. Para la mejor comprensión de los resultados, los mismos se dividirán según el comparador del sistema de elongación Precice® que se esté considerando. CONCLUSIONES: No se identificó evidencia de alta calidad que compare la efectividad para el alargamiento de miembros inferiores mediante el sistema Precice® respecto a los otros métodos de alargamiento y fijación. Evidencia de baja calidad proveniente de estudios observacionales sugiere que el uso del sistema de clavo endomedular motorizado Precice® presentaría una eficacia similar al uso de tutor externo monoplanar y tutor sobre clavo en alcanzar la longitud ósea deseada en el tratamiento de la discrepancia de longitud de miembros. Las ventajas del sistema Precice®respecto al tutor sobre clavo serían una mayor velocidad de alargamiento, menor tiempo de consolidación y mejor movilidad durante el tratamiento. Los pacientes que utilizaron el sistema endomedular, presentarían menor dolor, menor número de complicaciones y mayor satisfacción en cuanto a cosmesis y uso del sistema respecto al tratamiento con tutores externos. No se encontraron guías de práctica clínica acerca del tratamiento de la discrepancia en la longitud de los miembros por lo que no se pueden establecer las recomendaciones absolutas de su uso. Un financiador privado estadounidense brinda cobertura al uso del sistema Precice® para el alargamiento óseo. El resto de los financiadores estatales y privados consultados, de la Argentina y de otros países seleccionados, no mencionan a esta tecnología. No se cuenta con estudios económicos realizados en la Argentina acerca de la costo-efectividad de esta tecnología.

Serial Casting of the Ankle and Knee in a Child With Vascular Anomaly of the Calf Musculature: A Case Report.

BACKGROUND AND PURPOSE: Contracture and toe-walking in children due to vascular anomaly of the calf musculature is rarely described, and there is limited evidence regarding treatment. The purpose of this case is to describe the novel use of serial casting, combining the knee and ankle, to reduce contracture in a child with hemangioma of the calf. CASE DESCRIPTION: An 11-year-old girl received 12 casts of the ankle and knee, followed by custom orthotics, to address chronic contracture and gait impairments caused by a vascular anomaly in the posterior compartment of the lower extremity. OUTCOMES: After casting, the patient had fully restored knee range of motion and improved ankle range of motion by 45 degrees. She received custom orthotics and maintained her range of motion 4 months after casting. DISCUSSION: Serial casting of the knee and ankle may be a useful alternative to surgical lengthenings in patients with chronic contractures caused by vascular anomalies of the lower extremity.

Understanding Skeletal Growth and Predicting Limb-Length Inequality in Pediatric Patients.

Limb-length inequality in a child can be a complex condition for patients, parents, and medical providers. Managing these patients and explaining the treatment options to families requires knowledge of the potential risks associated with leaving a discrepancy untreated and a thorough understanding of skeletal growth. The provider must also be familiar with the available growth prediction methods as treatment is influenced by the anticipated discrepancy at skeletal maturity. This article provides an overview to skeletal growth, assessing skeletal maturity and growth prediction to help providers develop an organized and thoughtful approach to treating pediatric patients with limb-length inequalities.

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.

Recommendations for the follow-up of children with leg length discrepancy: expert consensus. / Recomendaciones para el seguimiento de niños con asimetría en la longitud de los miembros inferiores: consenso de expertos.

INTRODUCTION: Leg length discrepancy is when the length of one leg is different from the other, and is a common reason for consultation at the pediatrician's and pediatric orthopedist's office. The objective of this study was to develop recommendations for the follow-up, pre-surgical planning, and treatment of children with leg length discrepancy based on expert consensus. MATERIAL AND METHODS: The Delphi method was used. A coordinating group selected a panel of experts, designed and analyzed each of the rounds of consultations. Semistructured questionnaires were sent by personalized e-mail. Agreement among experts > 80 % was established as the criterion for consensus. At each round of consultation, non-consensual aspects were reformulated and new aspects suggested in the previous round were included. A measure of stability to conclude the consultation was determined when more than 70 % of experts sustained their opinion in successive rounds. RESULTS: Eight experts in orthopedics and six experts in imaging studies participated. After three rounds of consultations, consensus was reached in terms of 39 recommendations for follow-up, pre-surgical planning, and treatment. These were reorganized into 32 final recommendations. CONCLUSIONS: These are the first recommendations for the follow-up of children with leg length discrepancy agreed by expert consensus.

La asimetría de la longitud de los miembros inferiores es una afección en la cual la longitud de una pierna difiere de la contralateral, motivo de consulta frecuente en el consultorio del pediatra y del ortopedista infantil. El objetivo de nuestro trabajo fue desarrollar recomendaciones de seguimiento, planificación prequirúrgica y tratamiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos. Material y métodos. Se utilizó el método Delphi. Un grupo coordinador seleccionó el panel de expertos, diseñó y analizó cada una de las rondas de consulta. Los cuestionarios semiestructurados fueron enviados por correo electrónico en forma personalizada. Se estableció como criterio de consenso un acuerdo entre los expertos > 80 %. En cada una de las rondas, se reformularon los aspectos no consensuados y se agregaron nuevos sugeridos en la ronda anterior. Se consideró como medida de estabilidad para concluir la consulta cuando más del 70 % de los expertos no modificó su opinión en rondas sucesivas. Resultados. Participaron del consenso 8 expertos en ortopedia y 6 en diagnóstico por imágenes. Luego de 3 rondas de consulta, se logró el consenso en 39 recomendaciones referentes a seguimiento, planificación prequirúrgica y tratamiento. Fueron reagrupadas en 32 recomendaciones finales. Conclusiones. Estas son las primeras recomendaciones para el seguimiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos.

Correction of complex lower limb angular deformities with or without length discrepancy in children using the TL-HEX hexapod system: comparison of clinical and radiographical results.

The aim of this study was to compare clinical and radiographical results for treatment of lower limb multiaxial deformities±limb length discrepancy (LLD) of at least 2 cm with the Truelok hexapod fixator system (TL-HEX). All consecutive cases of lower limb multiaxial deformities were included. Patients were divided in two groups: group 1, lower limb angular deformity+LLD less than 2 cm, and group 2, lower limb angular deformity+LLD of at least 2 cm. Only patients with age younger than or equal to 20 years and follow-up of 6 months after removal of the external fixator were included. A total of 27 (six femur and 39 tibia treated) and 20 patients (12 femur and 19 tibia) were enrolled in groups 1 and 2, respectively. Complete correction of the deformity was achieved in 90 and 96% of the patients in groups 1 and 2, respectively. There were no differences in terms of external fixator, maturation, and distraction indexes between the two groups and between different anatomical sites. Good to excellent functional results (ASAMI score) were obtained in 93% of patients in group 1 and 75% in group 2 (P=0.01). Complication rate was similar between the two groups (7.4 vs. 10%, respectively). Average follow-up after removal of the external fixator was 25.6 (range: 7.0-54.0) months. The TL-HEX external fixator system allows a predictable correction of complex lower limb deformities regardless of the presence of LLD. Although complication rate is similar between the two groups, lower functional outcomes can be expected in patients with significant preoperative LLD.

Treatment of limb length discrepancy following total hip arthroplasty.

Limb length discrepancy is the leading cause of patient dissatisfaction following total hip arthroplasty and the most common reason for litigation in the field of orthopaedics. This article provides a systematic, stepwise approach for identifying the aetiology of limb length discrepancy following total hip arthroplasty and provides guidance on the treatment of this complication to optimize postoperative clinical and functional outcomes. This review discusses postoperative history taking, clinical examination, radiographic assessment, conservative treatment, and surgical intervention for the management of patients with established limb length discrepancy following total hip arthroplasty. A comprehensive understanding of the multifactorial nature and methods of managing postoperative limb length discrepancy is essential for optimizing patient satisfaction, clinical outcomes and long-term function following total hip arthroplasty.

[The complicated course of a femoral shaft fracture in childhood]. / Komplizierter Verlauf einer Femurschaftfraktur im Kindesalter.

We report a difficult healing process after a femoral shaft fracture in childhood. We present surgical correction options of femoral shortening due to pseudarthrosis after elastic stable intramedullary nailing. First, we tried to establish distraction using an external fixator, followed by plate osteosynthesis. After material failure of plate osteosynthesis, we treated the refracture with intramedullary nailing, after which bone healing occurred.

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.

[Surgical treatment for osteoarthritis secondary to Crowe type IV developmental dysplasia of hip in adults].

OBJECTIVE: To investigate the mothod and therapeutic efficacy of total hip anthroplasties (THA) for osteoarthritis secondary to Crowe type IV developmental dysplasia of hip in adults. METHODS: From May 2006 to December 2013, THA was performed on 15 adult patients (17 hips) with Growe type IV acetabular dysplasia, including 13 females and 2 males, with a mean age of 30.9 years old (22 to 58 years old) and an average preoperative Harris score of (34.0 ± 6.5) points. Traction of the affected limb was not performed before surgery. After extensive release and lengthening of soft tissues, sub-trochanteric osteotomy of the femur was performed, hip joint center was rebuilt and the abduction function was restored. RESULTS: The patients were followed up with a mean period of 33 months (ranged from 6 months to 5 years). The postoperative Harris score was 85.0 ± 7.3,higher than the preoperative score. The extended length of limb ranged from 1.6 to 5.4 cm, with a mean of (3.42 ± 0.65) cm. The shortening and malformation of the affected limb were corrected in the most patients,with the difference in length of the two legs less than 1.5 cm. After surgery, 1 patient experienced partial sciatic nerve injury, which was largely recovered after 3 months of conservative treatment. One patient experienced complete sciatic nerve injury, which was partially recovered after 6 months of conservative treatment; a foot-drop varus deformity was formed in the distal end of the affected limb, which was improved after tendon transposition and transplantation. Joint pain was relieved, and the joint function was restored significantly. Over the follow-up period, no severe complications such as dislocation, infection, prosthesis loosening, or subsiding occurred. CONCLUSION: Satisfactory efficacy can be achieved for adult Growe type IV acetabular dysplasia associated with osteoarthritis by THA, with proper soft tissue release and lengthening, sub-trochanteric osteotomy of femur, joint functional restoration, appropriate choice of prosthesis, and careful protection of nerves and vessels.

Leg Length Discrepancy in Primary Total Hip Arthroplasty.

Leg length discrepancy (LLD) is one of the most common complications of total hip arthroplasty. It may cause pain and disability to the patient, and it is the number one reason for filing a lawsuit against an orthopaedic surgeon. This manuscript reviews the preparation for and execution of the operative plan with emphasis on avoiding pitfalls leading to LLD. It also considers the treatment of LLD in the postoperative period.

[LIMB LENGH SHORTENING AFTER ARTERIAL CANNULATION IN INFANCY]. / Discrepancia de longitud de los miembros inferiores tras canalización arterial en niños.

OBJECTIVES: The aim of this study was to assess the relationship between arterial cannulations and the development of limb length discrepancies in childhood or impaired growth of the proximal femur. MATERIAL AND METHODS: A retrospective study was conducted on 300 children who required arterial cannulation and/or cardiac catheterisation during childhood in relation to congenital heart diseases. Seven of these patients were referred from the Paediatric Cardiology clinic due to a limb length discrepancy and/or proximal femoral deformities. RESULTS: Seven children, with a mean age of 10 years, were referred to our clinic. The mean length discrepancy was 2.7cm, and was more frequent on the right side. Three of the patients presented with proximal femoral deformities: two cases of caput valgum and one of bilateral physeal arrest of the greater trochanter. All children were initially treated with a shoe lift in the shortest limb. One of them required a tibial lengthening and two others are awaiting a similar procedure. CONCLUSION: We recommend clinical and radiological follow-up of patients who have undergone catheterisation during their infancy due to the relationship between these techniques and the risk of developing a limb length discrepancy.

Safety and Efficacy of Botulinum Toxin A in Children Undergoing Lower Limb Lengthening and Deformity Correction: Results of a Double-blind, Multicenter, Randomized Controlled Trial.

BACKGROUND: Lengthening of the lower limb is a complex procedure in which pain management and complications such as pin-site infections and muscle contractures impact the family and affect the child's quality of life. As a result, the paralytic and antinociceptive actions of neurotoxins may be indicated in managing these complications; however, few studies have explored ways to improve outcomes after lengthenings. The objective of this study was to evaluate the safety and efficacy of botulinum toxin A (BTX-A) in children undergoing lower limb lengthenings and deformity correction. METHODS: Participants with a congenital or acquired deformity of the lower extremity requiring surgery to one limb were randomized to receiving either BTX-A as a single dose of 10 units per kilogram body weight, or an equivalent volume of saline solution. Pain, medication, quality of life, and physical function were assessed at different time-points. Adverse events were recorded in all participants. T test and χ tests were used to compare potential differences across both groups. RESULTS: Mean age of the 125 participants was 12.5 years (range, 5 to 21 y), and lengthenings averaged 4.2 cm. Maximum pain scores on day 1 postoperatively were lower in the BTX-A group (P=0.03) than in the placebo group, and remained significant favoring botox when stratifying by location of lengthening (femur vs. tibia). Clinical benefits for BTX-A were found for 3 quality of life domains at mid-distraction and end-distraction. When stratifying according to location of lengthening, there were significantly fewer pin-site infections in the tibia favoring botox (P=0.03). The amount of adverse events and bone healing indices were no different in both groups. CONCLUSIONS: The clinical differences in quality of life, the lower pain on the first postoperative day, and the lower number of pin-site infections in the tibia favoring BTX-A support its use as an adjunctive treatment to the lengthening process. The detailed analyses of pain patterns help inform families on the pain expectations during lower limb lengthenings. The amount of adverse events were no different in both groups, and bone healing rates were similar, indicating that the use of BTX-A in children undergoing limb lengthening and deformity correction is safe. LEVEL OF EVIDENCE: Level I.