ARTICLE IN PRESS

Management of Mild Lower Extremity

Deformity and Leg Length Discrepancy
Alexander L. Kuzma, MD, and L. Reid Boyce Nichols, MD, FAOA, FAAOS

Limb malalignment and length discrepancy are common problems treated by pediatric
orthopaedic surgeons. These deformities may increase the rate of degenerative disease of
the knee, hip, and spine. Previous teaching suggested that there were no long term conse-
quences of mild deformity, however, newer studies suggest that there may be morbidity
associated with as little at 5 mm of leg length discrepancy. There are many etiologies that
can contribute to limb deformity, and so a thorough history and physical is key to manage-
ment. Pediatric patients present the unique opportunity to utilize the growth of the physis to
correct these deformities with adequate planning. Alternatively, lengthening techniques
have become safer and are associated with excellent patient satisfaction. The mounting evi-
dence of the long term consequences of leg deformity, coupled with more sophisticated
correction techniques, brings traditional indications for deformity correction into question.
Oper Tech Orthop 00:100874 © 2021 Elsevier Inc. All rights reserved.

KEYWORDS LLD, limb, length, discrepancy, lengthening, deformity

Introduction inches and is not complicated by a deviation of the static axis of

Malalignment
The alignment of the limb is defined by the mechanical axis.
This is formed by a line passing from the center of the femo-
ral head to the center of the ankle (Fig. 1). This line normally
passes through the center of the knee joint. Deviation from
the mechanical axis can be quantified to describe the mala-
lignment deformity. 1
the limb does not require operative treatment”.2 In 1978, a sur-
vey of 74 patients with leg length discrepancy greater than
1.5cm was performed.3 The survey consisted of only four ques-
tions regarding patient perceptions and presence of back pain.
The authors concluded that leg length discrepancy less than
2cm was unlikely to be symptomatic. This study has been
widely adopted in orthopaedic practice as a minimum indica-
tion for intervention. However, this study does not represent
definitive level I evidence.

Leg Length Discrepancy

A difference in leg lengths is common in the normal population.
The management of leg length discrepancy (LLD) can largely be
stratified by the magnitude of difference. In 1921, Vittorio Putti
stated that “shortening of the femur which does not surpass 2
Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for
Children, Wilmington, DE.
Conflict of Interest: Alexander L. Kuzma, MD: Nothing to disclose.
L. Reid Boyce Nichols, MD, FAOA, FAAOS: Consultant/Speaker Orthofix,
Orthopaedics, Smith & Nephew. Nothing to disclose pertinent to this paper.
Address reprint requests to L. Reid B. Nichols, MD, Department of
Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, 1600
Rockland Rd, Wilmington, DE 19803 E-mail: Reid.nichols@nemours.
org
Anatomy and Pathogenesis
The physis serves as the site of endochondral bone formation
and is responsible for longitudinal growth of the long bones.
The histologic zones of the physis have been well described
(Fig. 2) and an appreciation of the different growth potentials
in the various physes of the lower extremity is essential to
treatment of limb deformity (Fig. 3). Different pathology
may preferentially affect different zones of the physis. Physeal
injury can occur due to a number of causes including trauma,
ischemia, and infection, among others. The Heuter-Volk-
mann principle states that mechanical forces modulate
growth at the physis. Specifically, compression slows growth,
and tension may increase growth.5 40-50% of the variability

https://doi.org/10.1016/j.oto.2021.100874 1
1048-6666/© 2021 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 A.L. Kuzma and L.R.B. Nichols
Figure 1 Mechanical alignment superimposed on long leg radio-
graphs. The patient has a 2.8cm leg length discrepancy. Mechanical
alignment is near normal with mechanical axis passing through the
center of the knee joint.
in growth rate between physes is from chondrocyte hypertro-
phy, 30-40% is from matrix synthesis, and 10% is from
chondrocyte proliferation. This study found that mechanical
loading affects chondrocyte hypertrophy more than prolifera-
tion. Combining estimates of skeletal age with the growth
potential of a given physis is key to planning corrective sur-
gery in pediatric patients.
Natural History of Malalignment
Dysfunction in the lower extremities such as malalignment or leg
length discrepancy can lead to early joint degeneration. In 1991 a
cadaver study demonstrated that malalignment increased articu-
lar pressure.6 Both the magnitude and location of deformity were
important factors, with 20 degrees of proximal tibia varus increas-
ing medial compartment pressure by 106%. A clinical study
reported on a cohort of 17 patients with Blount’s disease that
found the incidence of arthritis increased by magnitude of defor-
mity.7 In a cohort of 88 tibial fracture patients, 43 went on to
Figure 2 Growth Zones of physis. Scheme of organization of the
growth plate, or physis. The histologically identifiable layers include
the resting or germinal layer and the proliferative, hypertrophic, and
provisional calcification layers progressing from epiphysis to meta-
physis. Reproduced with permission.1
malunion of 5 degrees or more. 58% of those with malunion
developed osteoarthritis over 15 years of follow-up versus 31%
of those with less than 5 degrees of malalignment (p = 0.02).8
Another study reported on a cohort of 52 femoral fractures, 21 of
whom went on to malunion with angulation greater than 10
degrees.9 6 of the 21 patients with malalignment developed oste-
oarthritis over 21 years of follow-up. The authors reported a posi-
tive correlation between coronal (r = 0.57, p < 0.001) and sagittal
(r = 0.44, p = 0.008) malalignment and osteoarthritis.
Natural History of Leg Length Discrepancy
Leg length discrepancy is common in the general population,
and the consequences of small leg length discrepancies are
unclear. In a cohort of 247 asymptomatic patients, 53 had leg
length discrepancy with the average magnitude of 5 mm.10 In a
meta-analysis including 573 patients in the general population,
90% had a leg length discrepancy of 1 mm or greater (Fig. 4).11
Although leg length discrepancies of less than 2 cm are com-
mon, the consequences of these small differences remain contro-
versial.12 Gross surveyed 74 adults with LLD of 1.5 cm or more.3
Patients with LLD less than 2 cm were significantly less likely to
consider the discrepancy a problem or feel unbalanced compared
with patients with greater discrepancy. Soukka et al. reported no
significant relationship between LLD less than 2 cm and low
back pain.10 Tallroth et al. followed this same cohort for 29 years,
however, and found that patients with LLD greater than 1 cm
had a three times higher rate of undergoing total knee arthro-
plasty.13 Harvey et al. examined the Multi-center Osteoarthritis
Study prospective cohort, and found that patients with LLD to
be at increased risk for knee osteoarthritis.14 This effect held true
for as little as 5 mm of discrepancy. Another study reviewed all
primary total hip arthroplasties performed in a single institution
over 2 years, and found that in a cohort of patients with mean
 ARTICLE IN PRESS
Management of Mild Lower Extremity Deformity and Leg Length Discrepancy 3

Figure 3 Approximate percentage of longitudinal growth provided by the proximal and distal physes at each long bone
in the upper (A) and lower (B) extremities. Reproduced with permission.4

Figure 4 Prevalence of LLD. The prevalence of various magnitudes of

leg length discrepancy within a cohort of 573 patients. Reproduced
with permission.11 https://creativecommons.org/licenses/by-nc/4.0/

7.5 mm LLD, the longer leg was a significant predictor of the side
of operation.15 Murray et al. found leg length discrepancy of
5 mm or more to be significantly associated with hip osteoarthri-
tis as well as degenerative disease of L5-S1.16 Gurney et al. simu-
lated the effects of LLD in formal gait analysis and noted
increased oxygen consumption and exertion with a 2 cm lift Figure 5 Full length lower extremity x-rays demonstrate leg length
added to healthy volunteers.17 discrepancy in a 16 year old male with a history of left distal femur
physeal fracture. Measurement reveals 3.5cm LLD.
Patient History and Physical Findings

 Careful assessment of joint motion supine and prone

 History primary complaint. Causative factors  Block test correction to level pelvis
 Gait toe walking, pelvic tilt, knee flexion, vaulting,  Rotational profile prone hip rotation, thigh foot
circumduction angle, transmalleolar axis
 ARTICLE IN PRESS
4 A.L. Kuzma and L.R.B. Nichols
 Neurovascular exam
 Recognize underlying syndromes
 Recognize soft tissue contractures
 Maximize bone health (calcium, vitamin D, nutrition)
and correct underlying endocrine factors
Imaging and Other Diagnostic Studies
 Full length standing x-rays. AP and Lateral. Magnification
marker, knees in full extension, level pelvis (Fig. 5).
 Hand x-ray for calculation of bone age (Fig. 6).
 CT Scanogram to assess rotational profile, also useful if
soft tissue contracture present. Selective CT scan cuts
can reduce radiation exposure (Fig. 7).
Treatment Options
Nonoperative
A shoe lift is the traditional non-operative management for leg
length discrepancy. A meta-analysis of patients with LLD and
either low back pain, scoliosis, hip pain or knee pain found a
shoe lift alleviated pain in 88% of subjects.18 Shoe lifts are not
always well tolerated by patients, whether due to limited shoe-
wear options or cosmesis, and are not always an appropriate
treatment. In patients with significant malalignment, there is
little role for observation alone as the definitive treatment.
Figure 6 Bone age x-ray in a 12 year old male with bone age
12.5 years by Greulich and Pyle atlas.
Figure 7 CT scanogram of 10 year old female with metaphyseal-
epiphyseal dysplasia and complex multiplanar deformity of the left
lower extremity.
Operative Management of Malalignment
Growth modulation represents a unique opportunity to
harness the potential of the physis in pediatric deformity
correction. Multiple techniques to correct angular defor-
mity have been described, including permanent hemiepi-
physiodesis versus reversible methods utilizing staples,
screws, or tension band plating. In a multicenter cohort
of 537 patients undergoing tension band plating, the
average correction rate was found to be 0.77° per month
in the distal femur and 0.79° per month in the proximal
tibia.19 Overall successful correction was 70% with femo-
ral deformities and 80% with tibial deformities. Tension
band plating for hemiepiphysiodesis has become increas-
ingly popular, however, there is a risk of failure both due
to hardware breakage as well as undercorrection. A
review of this technique recommended caution in older
patients with large deformity (> 20°) or obesity (BMI >
35). 20 These patients may be better served with an osteot-
omy with acute or gradual correction.
vOperative Management of Leg Length
Discrepancy
Determination of skeletal age is an important step for accu-
rate deformity correction. In a series of 77 patients, chrono-
logic age was discrepant from skeletal age by greater than 1
year 26% of bone age radiographs.21 In that series, use of
skeletal age reduced prediction errors compared to chrono-
logical age.
The next critical step of pre-operative planning con-
sists of determining future deformity. Multiple methods
of predicting future leg length discrepancy have been
described including the arithmetic method, growth
remaining method, straight-line graph method, and mul-
tiplier method. Makarov et al. compared these methods
in a cohort of 77 patients, and recommended use of the
 ARTICLE IN PRESS
Management of Mild Lower Extremity Deformity and Leg Length Discrepancy 5

Figure 8 Author’s preferred treatment algorithm for leg length discrepancy based on magnitude of deformity.

Figure 9 Long leg alignment views demonstrate 2.8cm discrepancy

between limbs with left side short.

arithmetic method with both increased accuracy and ease

of use.21 Little et al. reviewed a series of 71 epiphysiode-
sis cases, using various planning methods, and found
27% of patients had residual leg length difference of 2 cm
or greater. 22 Therefore, even with proper planning,
undercorrection remains a risk.
Epiphysiodesis often presents an ethical quandry for
patients, families and clinicians during discussion of treat-
ment options. The concept of shortening the “normal”
limb to correct deformity, and the resultant loss in
expected height, can be challenging to accept. Height has
been linked to social esteem, leader emergence, perfor-
mance, and income.23 A full discussion of treatment
options for leg length discrepancy includes not only epi-
physiodesis but also acute shortening and lengthening,
whether intramedullary or extramedullary.
Traditional methods of limb lengthening over external
fixators were fraught with complications of soft tissue con-
tracture, scarring, and pin site infections. A recent devel-
opment in the science of limb lengthening is the advent of
magnetically controlled intramedullary lengthening nails.
Intramedullary lengthening devices were associated with
less pain, improved cosmesis and improved patient satis-
faction compared to extramedullary techniques.24 These
devices were found to have a correction accuracy of 94%
and precision of 86% in one cohort.25
Figure 10 Bone age x-rays demonstrate skeletal age 14. The patient is
skeletally mature with little growth remaining.
Author’s Preferred Treatment
Algorithm
Important considerations for patient management include
symptoms, skeletal maturity, and magnitude of deformity
(Fig. 8). There is certainly evidence that small leg length dis-
crepancy can lead to symptoms, and using only absolute
number cut-offs may lead to sub-optimal outcomes. Though
limb equalization for greater than 2cm is generally accepted,
the evidence suggests symptomatic patients with LLD >1cm
may also benefit from correction.
Growth modulation is an important tool in the current era
of limb lengthening, as it can be used primarily for correction
or as an adjunct to lessen the amount of lengthening neces-
sary. Growth modulation is limited by the opportunity of
growth remaining, and so this is not an option in skeletally
mature patients.
 ARTICLE IN PRESS
6 A.L. Kuzma and L.R.B. Nichols
Figure 11 Treatment course over 1 year showing correction with lengthening rod. A. Presentation. B. 2 weeks post-
operative. C. 4 weeks post-operative. D. 6 weeks post-operative. E. 10 weeks post-operative. F. 14 weeks post-opera-
tive. G. 7 months post-operative. H. Hardware was removed at 1 year post-operative. Leg lengths corrected and osteot-
omy healed.
Hemiepiphysiodesis can also correct malalignment to
allow intramedullary lengthening, which is generally pre-
ferred by patients. Again, this is limited by growth remaining.
In skeletally mature individuals with both LLD and malalign-
ment, we typically use circular external fixation in order to
address all deformities present.
Finally, patients present with preconceived bias regarding
treatment. For instance, some patients may be averse to loss
in height implied with growth modulation techniques. A full
discussion of all treatment options, risks, and benefits, as
well as incorporating patient goals in decision making, is key
to success.
Case Example
12 year old female presents leg length discrepancy (Fig. 9).
She has noted limping since and feels her short leg is holding
her back from high level sports performance. She has noted
some low back pain as well. Examination demonstrated
2.8cm LLD with left side short, primarily due to femur. No
significant malalignment was identified. Her bone age was
found to be 14 years with little growth remaining (Fig. 10).
Diagnosis is congenitally short femur. Treatment options
were discussed with her and the patient strongly preferred
lengthening given her already short stature of 5 feet. Recon-
struction involved an internal lengthening over magnetically
guided intramedullary rod combined with iliotibial band
lengthening. The patient tolerated the procedure well and
began lengthening on post-operative day #5 at a rate of
1mm/day for 28 days (Fig. 11). Regenerate was then allowed
to consolidate and finally hardware was removed at 1 year
post-operatively.
Conclusion
Pediatric patients present the unique opportunity to utilize the
growth of the physis to correct lower extremity angular defor-
mities and length discrepancies with adequate planning.
Mounting evidence suggests that even mild malalignment and
leg length discrepancy can increase risk for long term muscu-
loskeletal degenerative pain. Treatment options for these
deformities have evolved to become more precise and carry
less morbidity for the patient. Future studies will help us iden-
tify ideal indications for deformity correction, and, meanwhile,
it is important to question historic thresholds for intervention.
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