What are the treatment options for a patient with leg length discrepancy?

Treatment Options for Leg Length Discrepancy

For leg length discrepancies, treatment should be stratified by the magnitude of discrepancy: conservative management with shoe lifts for discrepancies up to 2-3 cm, epiphysiodesis or shortening osteotomy for 3-5 cm discrepancies, and bone lengthening procedures for discrepancies of 5-15 cm or greater. 1, 2, 3

Initial Assessment Requirements

Before determining treatment, several key factors must be evaluated:

• Measure the exact magnitude of leg length discrepancy using reliable radiologic methods, as this is the primary determinant of treatment strategy 2, 4
• Assess skeletal maturity and bone age in pediatric patients, as this determines eligibility for growth-modulating procedures 1, 5
• Evaluate limb alignment in coronal and sagittal planes and assess the torsional profile to identify any associated deformities 1
• Refer patients with significant limb deformities to an orthopedic surgeon with experience in metabolic bone disease 1

Conservative Management (Discrepancies ≤2-3 cm)

For smaller discrepancies, non-surgical approaches are appropriate:

• Shoe lifts or orthotic devices are the primary conservative treatment for discrepancies up to 2-3 cm 3, 6
• Physical therapy should address compensatory mechanisms that develop from the discrepancy 1
• Emphasize weight-bearing exercise, maintenance of joint range of motion, and maximizing strength as part of conservative management 1
• Monitor for musculoskeletal complaints in the knee or hip that can develop from acquired limb-length discrepancy from orthotic devices 1, 7

A critical caveat: While the connection between leg length discrepancy and back pain is questionable, there appears to be a mildly elevated incidence of knee arthritis with untreated discrepancies 2.

Surgical Management for Growing Children

Epiphysiodesis (Discrepancies 3-5 cm)

For pediatric patients with open growth plates and discrepancies of 3-5 cm, epiphysiodesis (growth plate blockade) around the knee joint is the gold standard approach 2, 5:

• Percutaneous epiphysiodesis techniques are minimally invasive, safe, and efficient with low complication rates 5
• Guided growth techniques may be considered for pediatric patients if growth plates are still open 1
• Timing is critical: Growth prediction algorithms can estimate final leg length discrepancy to within 2 cm, but adequate planning is key for success 2, 5
• LLD corrections up to 5 cm can be achieved with this technique 5

Bone Lengthening (Discrepancies ≥5 cm)

For predicted discrepancies exceeding 5 cm, initial leg-lengthening treatment should be considered during the patient's growing years 2:

• Osteotomy with distraction of bone callus using fully implanted or external apparatus (Ilizarov, Orthofix) is the primary technique 2, 3
• Modern techniques using corticotomy and callus distraction have made bone lengthening less risky, easier, and more effective 3
• Excellent results were obtained in 65% and good results in 23% of patients undergoing distraction procedures 3
• Be aware that changes in leg length exert marked mechanical stress on soft tissues, which must be managed carefully 2

Combined Approaches

For severe discrepancies (>15 cm):

• Bone lengthening combined with shortening procedures on the contralateral side can establish leg length equality even with discrepancies up to 20 cm 3
• A multidisciplinary approach involving orthopedic surgeons, endocrinologists (when metabolic causes are present), and physical therapists is essential 5

Monitoring and Follow-up

Regular follow-up is essential to assess the effectiveness of intervention and monitor for development of secondary complications 1:

• Repeated clinical and radiological assessment with analysis of past growth helps predict future growth and refine treatment plans 3
• Monitor for development of compensatory gait abnormalities and joint complaints 1, 6

Key Clinical Pitfalls

• The extent of discrepancy is not the sole determining factor for treatment mode—patient age, skeletal maturity, functional impairment, and patient preference all play roles 2
• Growth prediction carries inherent error, so conservative estimates and careful timing are crucial for epiphysiodesis success 5
• The decision to treat is always elective, and must be discussed individually with each patient 2
• Avoid overtreatment: Not all leg length discrepancies require intervention, and unnecessary treatment can be costly and potentially harmful 8