Association of leg-length inequality with knee osteoarthritis: a cohort study

Lower extremity length discrepancy solution by modified drilling epiphysiodesis and anthropological prediction methods: long-term results

This study aimed to summarize our experience with modified drilling epiphysiodesis and prediction methods for accurate timing of surgery and to compare the results with those of recent work by other authors. The Macnicol and Gupta modified drilling technique was used. Distal femoral and/or proximal tibial permanent epiphysiodesis was performed in 42 children (21 boys, 21 girls; median age at surgery=12.6 years, age range=9.4-15.4 years) between 2004 and 2016. Based on the groundwork of previous studies, we developed an auxological prediction method. The limb length discrepancy (LLD) was assessed by clinical examination and verified by an x-ray of the hips when standing with blocks under the shorter leg. The predicted shortening was 2.7 cm ± 1.1 cm. The final discrepancy after finishing skeletal growth was 0.5 ± 0.5 cm. In 26 patients (61.9%), equalization of both legs was achieved (0-0.5 cm). In 4 patients (9.5%), the remaining shortening was more than 1.0 cm. Shortening of an initially longer leg occurred in two patients (0.5 cm and 0.6 cm). Failure of growth plate arrest was observed in 1 patient. In another 3 patients, the efficacy of tibial epiphysiodesis was unsatisfactory. Minor complications occurred in 5 cases, but there was no evidence of angular deformity in the frontal and sagittal planes or proximal fibula overgrowth. Three patients (7.1%) returned to the operating room. Compared to published data, more patients achieved complete equalization of leg length. The results of this study verified the accuracy of the auxological prediction algorithm of LLD based on Shapiro's findings. The surgical outcome is comparable between Shapiro patterns 1 and 3. Auxological examination, assessment of bone age, and sexual maturation are crucial tools for accurate timing of surgery.

The reliability of clinical tools with and without ultrasound guidance to measure leg-length inequality

Purpose

To determine and compare the reliability and efficiency of various methods of leg-length measurement.

Methods

A total of 88 leg-lengths were measured among 50 subjects (79%-84% female, mean age = 30-33 years). Leg-lengths were measured in both supine and standing positions using multiple devices, including a tape measure, a LASER distance meter, and diagnostic ultrasound.

Results

All methods of leg-length measurement using the middle of the femoral head as a reference point, identified via ultrasound, demonstrated excellent reliability (intraclass correlation coefficient = 0.95-1.00). Measurements performed in supine, using the anterior superior iliac spine as a reference point, with a tape measure, demonstrated good-to-excellent reliability (intraclass correlation coefficient = 0.86-0.95, standard error of the measurement = 16.1-19.9 cm). Standing measurements using the anterior superior iliac spine as a reference point, using a tape measure, demonstrated fair-to-excellent reliability (intraclass correlation coefficient = 0.71-0.95).

Conclusion

Ultrasound-guided landmark identification appear to be a more reliable method compared to palpation of the anterior superior iliac spine for measurement of leg-length using clinical tools. When coupled with ultrasound guidance, a hand-held LASER distance meter/pitch locator apparatus or a retractable tape measure appears to be acceptable alternatives to a fixed LASER distance meter on a linear actuator for leg-length measurement.

Acute Correction of Leg Length Discrepancy and Severe Femoral Malalignment: A Case Report

Introduction

Approximately 70% of the population have a leg length discrepancy, with 2 cm being the threshold for surgical treatment. Although there are reports of patient outcomes after incremental leg-lengthening, there is a paucity of data regarding acute lengthening procedures. We present a unique case of acute leg lengthening and correction of severe malalignment in an adult patient after femoral malunion treated with multiple modified Sofield-Millar osteotomies and intramedullary nailing, a technique that has only previously been performed in pediatric long bone deformities. To the author's knowledge, there have been no previous reports of acute lengthening in an adult patient to correct for such a severe deformity in a single operation.

Case Report

A 48-year-old woman with a 35-year history of a right femur fracture malunion presented with a 5 cm leg length discrepancy and severe malalignment associated with pain and ambulatory dysfunction. Multiple modified Sofield-Millar osteotomies followed by placement of an intramedullary nail were performed and resulted in successful acute correction of limb length discrepancy and anatomical alignment. There was a complete union of bone with callus formation at osteotomy sites at 9 months postoperatively, and the patient reported minimal pain and improved ambulation. The patient was followed for 2 years postoperatively and experienced an improvement in ambulatory function with no pain. No post-operative complications were observed.

Conclusion

Multiple modified Sofield-Millar osteotomies with intramedullary nailing were utilized for successful acute correction of limb length discrepancy and severe malalignment with improvement in pain and ambulatory function in this case of femoral leg length discrepancy in an adult patient.

ILIAC CREST HEIGHT DIFFERENCE AND OTHER RUNNING-RELATED VARIABLES' RELATIONSHIP WITH RUNNING INJURY

BACKGROUND

Leg-length inequality (LLI) is a common condition that may contribute to various spinal, pelvic, and lower extremity dysfunctions. Iliac crest height difference (ICHD) has been demonstrated to be a good estimate for LLI and may be a useful measure for identifying individuals who are at risk for injury.

PURPOSE

To investigate the relationship between ICHD and other running-related variables with running injury.

METHODS

An observational retrospective case-control design was used. Data were collected via questionnaire and physical examination from a purposive sample of 100 runners and were analyzed using chi-squared tests of independence.

RESULTS

The prevalence of ICHD ≥ 5mm reported by subjects via questionnaire was ∼40%. There was no difference in report of injury between subjects with ICHD >5mm and those with ICHD <5mm (χ² = 0.02, p = 0.88); however, lifetime history of injury (χ² = 15.68, p = 0.00) and the number of running events participated (χ² = 3.09, p = 0.04) were significant factors associated with injury; although not significant, there was a trend towards relationship with gender (χ² = 3.2, = 0.07).

CONCLUSION

Small ICHD is not associated with running injury among recreational runners. There appears to be an increased risk of running injury among runners who participate in more than one running event annually and those that have had a past history of running injury. Also, males may be at slightly greater risk of sustaining a running injury compared to females.

LEVEL OF EVIDENCE

Therapy, level 3b.

[Motion analysis on patients with knee osteoarthritis merged with varus deformity]

Aiming at comparing the pre-operative and post-operative gait characteristics and therefore establishing post-operative rehabilitation guidance for patients with end-stage knee osteoarthritis (KOA) merged with varus deformity, this study captured the level walking and sit-to-stand trials of 9 patients with 3-dimensional motion analysis system and after which musculoskeletal multi-body dynamic analysis was conducted. The study indicated that the average range of motion (ROM) of the proposed-surgical knee was 24.4°-57.6° and that of the non-surgical knee was 22.5°-71.5°. The knee ROM of control group during level walking was 7.2°-62.4°. When the unilateral KOA patients stood up from chair to complete the sit-to-stand movement, the ground reaction forces (GRFs) symmetry was 0.72-0.85, which means that the non-surgical limb bear the majority of body weight. The GRFs of the bilateral KOA patients were smallest during the sit-to-stand movement. The strategy that the non-surgical limb dominates in loading bearing taken by the unilateral KOA patients to cover most post-operative daily activities could increase the risk of KOA among non-surgical side joints as a result of long-term excessive loading-bearing. The study, on kinematics and biomechanical characteristics of patients with KOA merged with varus deformity, could help to understand the pathogenesis of KOA merged with varus deformity from the perspective of biomechanics and to provide strong clinic guidance for the pre-operative evaluation, prevention and post-operative recovery for patients.

The role of thermal balneotherapy in the treatment of obese patient with knee osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis clinically characterized by joint pain, functional limitation, and reduced quality of life. Several studies have shown a clear link between obesity and higher risk of knee OA. According to the multifactorial OA pathogenesis, the management of this condition requires a multidisciplinary approach. The objective of this study is to evaluate hydrokinesitherapy effects in thermal setting in obese patients with knee OA. Fifty-three patients were assessed for eligibility, of which 33 refused the treatment, while 10 patients dropped out after the enrollment for personal reasons or inability to adhere to the program. Ten patients (8 females, 2 males, mean age of 59.4 years) with obesity (range BMI 30-45 kg/m2) and knee OA (II-III grade of Kellgren-Lawrence scale) treated with hydrokinetic therapy in thermal water (two sessions per week for 8 consecutive weeks) completed the study. Primary outcome measure was pain (VAS). Secondary outcomes were clinical knee evaluation (range of motion-ROM, lower-limb muscle strength), WOMAC, and Lequesne Algofunctional Index. Patellar tendon and peri-articular soft tissue ultrasound evaluation and gait analysis at baseline (T0), at the end of treatment (T1), and at 6 months of follow-up (T2) were performed. Significant decrease on VAS pain during walking on a flat surface and going up/down stairs was reached from baseline at T1 (p = 0.0039; p = 0.0098) and was maintained at T2 (p = 0.00954) exclusively for VAS pain during walking on a flat surface. WOMAC score showed a significant reduction between T0 and T1 (p = 0.0137) and between T0 and T2 (p = 0.006438), as ROM evaluations. Kinematic path assessment did not show significant results in individual gait steps, except for the space-time variables of the average speed and the values of ground reaction force (GRF) obtained with force platforms. Hydrokinesitherapy in thermal environment in obese patients with knee OA may determine pain relief, joint function improvement, and walking speed increase until 6 months of follow-up.

Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine

Osteoarthritis (OA) is an extremely common condition that creates substantial personal and health care costs. An important recognised risk factor for OA is excessive or abnormal mechanical joint loading. Leg length discrepancy (LLD) is a common condition that results in uneven and excessive loading of not only knee joints but also hip joints and lumbar motion segments. Accurate imaging methods of LLD have made it possible to study the biomechanical effects of mild LLD (LLD of 20mm or less). This review examines the accuracy of these methods compared to clinical LLD measurements. It then examines the association between LLD and OA of the joints of the lower extremity. More importantly, it addresses the largely neglected association between LLD and degeneration of lumbar motion segments and the patterns of biomechanical changes that accompany LLD. We propose that mild LLD may be an important instigator or contributor to OA of the hip and lumbar spine, and that it deserves to be rigorously studied in order to decrease OA's burden of disease.

Pilot study of the impact that bilateral sacroiliac joint manipulation using a drop table technique has on gait parameters in asymptomatic individuals with a leg length inequality

PURPOSE

The purpose of this study was to pilot test our study procedures and estimate parameters for sample size calculations for a randomized controlled trial to determine if bilateral sacroiliac (SI) joint manipulation affects specific gait parameters in asymptomatic individuals with a leg length inequality (LLI).

METHODS

Twenty-one asymptomatic chiropractic students engaged in a baseline 90-second walking kinematic analysis using infrared Vicon® cameras. Following this, participants underwent a functional LLI test. Upon examination participants were classified as: left short leg, right short leg, or no short leg. Half of the participants in each short leg group were then randomized to receive bilateral corrective SI joint chiropractic manipulative therapy (CMT). All participants then underwent another 90-second gait analysis. Pre- versus post-intervention gait data were then analyzed within treatment groups by an individual who was blinded to participant group status. For the primary analysis, all p-values were corrected for multiple comparisons using the Bonferroni method.

RESULTS

Within groups, no differences in measured gait parameters were statistically significant after correcting for multiple comparisons.

CONCLUSIONS

The protocol of this study was acceptable to all subjects who were invited to participate. No participants refused randomization. Based on the data collected, we estimated that a larger main study would require 34 participants in each comparison group to detect a moderate effect size.

Epidemiology of osteoarthritis

Osteoarthritis (OA) is the most common joint disorder in the United States. Symptomatic knee OA occurs in 10% men and 13% in women aged 60 years or older. The number of people affected with symptomatic OA is likely to increase due to the aging of the population and the obesity epidemic. OA has a multifactorial etiology, and can be considered the product of an interplay between systemic and local factors. Old age, female gender, overweight and obesity, knee injury, repetitive use of joints, bone density, muscle weakness, and joint laxity all play roles in the development of joint OA, particularly in the weight-bearing joints. Modifying these factors may reduce the risk of OA and prevent subsequent pain and disability.