What is the recommended treatment plan for a 37-year-old male patient with a metallic foreign body (BB) partially embedded in the anterior cortex of the mid right tibia, a leg length discrepancy due to pelvic tilt, and a history of gunshot wound and healed diaphyseal fracture?

Management of Metallic Foreign Body in Tibia with Leg Length Discrepancy

The recommended treatment for this 37-year-old male patient with a metallic BB embedded in the anterior tibial cortex and leg length discrepancy is observation of the foreign body with no surgical removal needed, combined with orthotic shoe correction for the leg length discrepancy.

Assessment of the Metallic Foreign Body

Foreign Body Evaluation

• The radiographic findings show a 4.5 mm metal pellet partially embedded in the anterior cortex of the mid right tibia without associated fracture
• According to ACR guidelines, metallic foreign bodies that are stable and not causing symptoms generally do not require removal 1
• The foreign body appears to be stable within the cortex without signs of:
  • Active infection
  • Migration
  • Cortical disruption or fracture
  • Soft tissue inflammation

Risk-Benefit Analysis

• Surgical removal of the embedded BB carries risks:
  • Potential destabilization of the tibial cortex
  • Surgical site infection
  • Anesthesia complications
  • Possible need for more extensive fixation if the cortex is compromised during removal

Management of Leg Length Discrepancy

Assessment of Discrepancy

• The patient has a 2.5 cm leg length discrepancy due to pelvic tilt
• Right acetabulum and plafond are 2.5 cm higher than the left
• The discrepancy makes the right lower extremity appear shorter than the left when non-weightbearing

Treatment Options

• For leg length discrepancies between 2-3 cm, conservative management with shoe lifts is the standard of care 2
• Surgical options would typically be considered for discrepancies >3 cm, but given this patient's history of prior femoral fracture with intramedullary rod placement, conservative management is preferred 3
• The prescription of orthotic shoes is appropriate for this degree of discrepancy

Treatment Plan

1. Foreign Body Management:

   • Observation of the metallic BB without surgical intervention
   • Regular radiographic follow-up every 6-12 months to ensure stability

2. Leg Length Discrepancy Management:

   • Custom orthotic shoe with appropriate lift to compensate for the 2.5 cm discrepancy
   • Gradual adjustment to the lift may be necessary for patient comfort and adaptation

3. Follow-up Care:

   • Monitor for any signs of:
     • Pain at the site of the foreign body
     • Skin changes or drainage
     • Progressive leg length discrepancy
     • Gait abnormalities or secondary joint pain

Potential Complications to Monitor

• Secondary osteoarthritis in weight-bearing joints due to biomechanical alterations
• Low back pain from pelvic obliquity
• Adaptive muscle shortening or weakness
• Failure of orthotic correction to adequately address functional limitations

Conclusion

The embedded metallic BB in the tibial cortex without associated fracture or infection does not require surgical removal. The leg length discrepancy is best managed with orthotic shoe correction. This approach minimizes surgical risks while addressing the functional impact of the leg length discrepancy.