Slide 041 — LLD

Clean FRCS notes with inline figures

Clinical photograph

•Block test

•Right LL shorter by ~5cm

•Both femur and tibia are involved

•Foot and ankle no gross deformity

•No skin stigmata (Café au lait spots in NF in tibial pseudoarthrosis)

•Presence of all 5 toes (fibular hemimelia)

OVERALL:

•Look for deformity: LLD / angular / rotation

Cause:

•Hemihypertrophy: Vascular, NF

•Shortening: Neurological, congenital, local (physis)

•Bone age (clinical / radiological)

•Predict LLD (Shapiro + calculations)

•Management plan: conservative / epiphysiodesis / lengthening / amputation

•Cause of LLD

Long leg:

•Congenital hemihypertrophy (e.g. NF, Klippel Trenaunneay, Beckwidth Wiedemann, Proteus)

•Physeal stimulation (post traumatic)

Short leg:

•Congenital (DDH, fibular hemimelia, PFFD, calcaneovalgus, enchondromatosis)

•Neuromuscular (polio, cerebral palsy)

•Vascular (Perthes, AV fistula)

•Physis (physis bar, hyperemia): trauma, infection, tumor

Management:

•Assess cause (from femur/ tibia)

•Assess skeletal maturity (clinical, radiological)

•Calculate LLD at maturity

•Assess function of foot and ankle (joint mobility and stability)

•R/O other deformity (angular, rotational, LL contracture)

•Assess skeletal maturity

•Clinical

•Chronological age

•Tanner staging (1st sign: enlargement of testis, breast bud. Descending phase: menarche/axillary hair)

•Menarche

•Growth spurt

•Radiological

•1. Tanner Whitehouse (With reference to the morphology and fusion of physis in hand and wrist)

•2. Gruelich and Pyle atlas (DP→MC→PP→MP→ulnar→radius)

•3. Risser

•4. Elbow epiphyseal centre (Sauvergain)

•Calculation for LLD at maturity

Multiple FU:

•1 Moseley chart (need leg length of both LL and Xray hand for skeletal maturity)

•2 Arithmetic method (calculate growth inhibition and predict LLD by future growth in long leg x inhibition)

•Assumption: distal femur 9mm/yr, proximal tibia 6mm/yr, boy stop growth 16, girl 14, Shapiro type 1

•3 Green Anderson chart

Single FU:

•1 Paley multiplier method (LLD X age and sex factor)

•2 Simplistic

•Also taken into consideration Shapiro’s growth pattern

•LLD proportionally increase: Physeal arrest, PFFD – Most common, static growth inhibition

•LLD growth decelerates: NM conditions

•LLD static after a while: Overgrowth of femur fracture

•LLD static after a while then increase again: Perthes

•LLD plateau and reduce: JRA

General principles:

•Depends on the LLD at skeletal maturity

•<2cm: observe (manage with shoe raise)

•2-5cm: shorten longer limb by epiphysiodesis if physis open, shortening osteotomy if physis closed

•>5cm: lengthen short limb +/- shorten long limb

•>20cm: consider amputation

•Lengthening techniques (lengthen the short side)

Acute

•Gradual

•Distraction histiogenesis

•Gradual lengthening procedure by intramembranous ossification, use of distraction force to stimulate the formation of bone and soft tissue

Procedure:

**Fig 1.** Operative / approach imagetop left

•Put on exfix

•Perform low energy corticotomy at metaphyseal region (transecting 2/3 of circumference of cortex and complete by osteoclasis by rotating the proximal and distal segment in opposite direction. Preserve the periosteum, endosteum, medullary content and nutrient artery ) OR osteotomy (multiple drill holes followed by completion by osteotome) = no difference in the literature

•Rest for 5-7days

•Gradual distraction (1mm per day divided into 4 times)

•Consolidation ~2x time of lengthening, need Xray to confirm formation of at least 3 cortex

•Removal of exfix when there is closure of interzone and 2 side neocorticalisation on AP and lat films

•Maximum lengthening each time: 20%

•(Michael To tutorial: JPO 2010? % Lengthening related to % of complication, if lengthening >20% → increase complication e.g. nonunion, NV injury, infection, contracture)

Complication:

•Angular deformity

•Pin tract infection

•Nerve injury (during OT/ traction injury)

•Fracture due to early removal of ex fix

•Chondrodiastasis

•Gradual distraction of physis result in hypertrophy of cellular layers of the physis without separation - Heuter Volkman

•Unpredictable results

•initial lengthening is often followed by growth plate fusion

•Shortening techniques (shorten the long side)

•Permanent

•Open epiphysiodesis (Phiemester)

•Remove rectangular portion of bone containing metaphysis, physis and epiphysis. Flip around and reinsert to create bone bridge

•Adv: predictable outcome

•Disadv: irreversible, long rehab, extensive dissection, angular deformity, exostosis

•Percutaneous epiphysiodesis (Bowen)

•Stab wound. Longitudinal periosteum split + physis penetration 5mm by osteotome. Peripheral 1/3 ablated by curette. Done on both medial and lateral side

•Temporary

•Staples

•8 plate

•Transphyseal screw

•Combo

Histology in distraction histiogenesis?

•Central fibrous interzone: fibroblasts activated and secrete collagen parallel to distraction force. Provides undifferentiated mesenchymal cell which directly transform into osteoblast → intramembranous ossification

•Zone of microcolumn formation: osteoblast aligns collagen to longitudinal column and promotes blood vessel invasion to lay down osteoid

•Factors that affect distraction

•Stability of fixation

Type and site of osteotomy

•Ilizarov compared 3 different types of osteotomies (open, percutaneous corticotomy, complete closed) recommend percutaneous corticotomy.

•Metaphysis with more osteogenic potential, soft tissue better adapted to lengthening

•Distraction regime

•Latency prior to distraction allows inflammatory phase to subside. Distraction during reparative phase. (3 days for child, 7-14days for adult)

•Rate 1mm/day

•Rhythm – frequency of applying distraction (4 times/day), increase frequency increase distraction

Complications

•Bone related

•Incomplete consolidation

•Premature consolidation

•Fracture

•Growth disturbance of lengthened bone

•Implant related

•NV injury

•Pin tract infection

•Joint contracture + subluxation

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Describe photo:
2	0	171450	-171450	1	Block test
3	0	171450	-171450	1	Right LL shorter by ~5cm
4	0	171450	-171450	1	Both femur and tibia are involved
5	0	171450	-171450	1	Foot and ankle no gross deformity
6	0	171450	-171450	1	No skin stigmata (Café au lait spots in NF in tibial pseudoarthrosis)
7	0	171450	-171450	1	Presence of all 5 toes (fibular hemimelia)
8	0	0	0	0	OVERALL:
9	0	228600	-228600	1	Look for deformity: LLD / angular / rotation
10	0	228600	-228600	1	Cause:
11	1	457200	0	1	Hemihypertrophy: Vascular, NF
12	1	457200	0	1	Shortening: Neurological, congenital, local (physis)
13	0	228600	-228600	1	Bone age (clinical / radiological)
14	0	228600	-228600	1	Predict LLD (Shapiro + calculations)
15	0	228600	-228600	1	Management plan: conservative / epiphysiodesis / lengthening / amputation
16	0	0	0	0	Cause of LLD
17	0	0	0	0	Long leg:
18	1	628650	-171450	2	Congenital hemihypertrophy (e.g. NF, Klippel Trenaunneay, Beckwidth Wiedemann, Proteus)
19	1	628650	-171450	2	Physeal stimulation (post traumatic)
20	0	0	0	0	Short leg:
21	1	628650	-171450	2	Congenital (DDH, fibular hemimelia, PFFD, calcaneovalgus, enchondromatosis)
22	1	628650	-171450	2	Neuromuscular (polio, cerebral palsy)
23	1	628650	-171450	2	Vascular (Perthes, AV fistula)
24	1	628650	-171450	2	Physis (physis bar, hyperemia): trauma, infection, tumor
25	0	0	0	0	Management:
26	0	228600	-228600	1	Assess cause (from femur/ tibia)
27	0	228600	-228600	1	Assess skeletal maturity (clinical, radiological)
28	0	228600	-228600	1	Calculate LLD at maturity
29	0	228600	-228600	1	Assess function of foot and ankle (joint mobility and stability)
30	0	228600	-228600	1	R/O other deformity (angular, rotational, LL contracture)
31	0	0	0	0	Assess skeletal maturity
32	0	0	0	0	Clinical
33	1	685800	-228600	2	Chronological age
34	1	685800	-228600	2	Tanner staging (1st sign: enlargement of testis, breast bud. Descending phase: menarche/axillary hair)
35	1	685800	-228600	2	Menarche
36	1	685800	-228600	2	Growth spurt
37	1	457200	0	1	Radiological
38	1	457200	0	1	1. Tanner Whitehouse (With reference to the morphology and fusion of physis in hand and wrist)
39	1	457200	0	1	2. Gruelich and Pyle atlas (DP→MC→PP→MP→ulnar→radius)
40	1	457200	0	1	3. Risser
41	1	457200	0	1	4. Elbow epiphyseal centre (Sauvergain)
42	0	0	0	0	Calculation for LLD at maturity
43	0	0	0	0	Multiple FU:
44	1	457200	0	1	1 Moseley chart (need leg length of both LL and Xray hand for skeletal maturity)
45	1	457200	0	1	2 Arithmetic method (calculate growth inhibition and predict LLD by future growth in long leg x inhibition)
46	2	914400	0	3	Assumption: distal femur 9mm/yr, proximal tibia 6mm/yr, boy stop growth 16, girl 14, Shapiro type 1
47	1	457200	0	1	3 Green Anderson chart
48	0	0	0	0	Single FU:
49	1	457200	0	1	1 Paley multiplier method (LLD X age and sex factor)
50	1	457200	0	1	2 Simplistic
51	0	0	0	0	Also taken into consideration Shapiro’s growth pattern
52	1	685800	-228600	2	LLD proportionally increase: Physeal arrest, PFFD – Most common, static growth inhibition
53	1	685800	-228600	2	LLD growth decelerates: NM conditions
54	1	685800	-228600	2	LLD static after a while: Overgrowth of femur fracture
55	1	685800	-228600	2	LLD static after a while then increase again: Perthes
56	1	685800	-228600	2	LLD plateau and reduce: JRA
57	0	0	0	0	General principles:
58	0	0	0	0	Depends on the LLD at skeletal maturity
59	1	628650	-171450	2	<2cm: observe (manage with shoe raise)
60	1	628650	-171450	2	2-5cm: shorten longer limb by epiphysiodesis if physis open, shortening osteotomy if physis closed
61	1	628650	-171450	2	>5cm: lengthen short limb +/- shorten long limb
62	1	628650	-171450	2	>20cm: consider amputation
63	0	0	0	0	Lengthening techniques (lengthen the short side)
64	0	171450	-171450	1	Acute
65	0	171450	-171450	1	Gradual
66	1	628650	-171450	2	Distraction histiogenesis
67	1	628650	-171450	2	Gradual lengthening procedure by intramembranous ossification, use of distraction force to stimulate the formation of bone and soft tissue
68	1	628650	-171450	2	Procedure:
69	2	1143000	-228600	3	Put on exfix
70	2	1143000	-228600	3	Perform low energy corticotomy at metaphyseal region (transecting 2/3 of circumference of cortex and complete by osteoclasis by rotating the proximal and distal segment in opposite direction. Preserve the periosteum, endosteum, medullary content and nutrient artery ) OR osteotomy (multiple drill holes followed by completion by osteotome) = no difference in the literature
71	2	1143000	-228600	3	Rest for 5-7days
72	2	1143000	-228600	3	Gradual distraction (1mm per day divided into 4 times)
73	2	1143000	-228600	3	Consolidation ~2x time of lengthening, need Xray to confirm formation of at least 3 cortex
74	2	1143000	-228600	3	Removal of exfix when there is closure of interzone and 2 side neocorticalisation on AP and lat films
75	1	628650	-171450	2	Maximum lengthening each time: 20%
76	1	457200	0	1	(Michael To tutorial: JPO 2010? % Lengthening related to % of complication, if lengthening >20% → increase complication e.g. nonunion, NV injury, infection, contracture)
77	1	628650	-171450	2	Complication:
78	2	1085850	-171450	3	Angular deformity
79	2	1085850	-171450	3	Pin tract infection
80	2	1085850	-171450	3	Nerve injury (during OT/ traction injury)
81	2	1085850	-171450	3	Fracture due to early removal of ex fix
82	1	628650	-171450	2	Chondrodiastasis
83	1	628650	-171450	2	Gradual distraction of physis result in hypertrophy of cellular layers of the physis without separation - Heuter Volkman
84	2	1085850	-171450	3	Unpredictable results
85	2	1085850	-171450	3	initial lengthening is often followed by growth plate fusion
86	0	0	0	0	Shortening techniques (shorten the long side)
87	0	0	0	0	Permanent
88	0	171450	-171450	1	Open epiphysiodesis (Phiemester)
89	1	628650	-171450	2	Remove rectangular portion of bone containing metaphysis, physis and epiphysis. Flip around and reinsert to create bone bridge
90	1	628650	-171450	2	Adv: predictable outcome
91	1	628650	-171450	2	Disadv: irreversible, long rehab, extensive dissection, angular deformity, exostosis
92	0	171450	-171450	1	Percutaneous epiphysiodesis (Bowen)
93	1	628650	-171450	2	Stab wound. Longitudinal periosteum split + physis penetration 5mm by osteotome. Peripheral 1/3 ablated by curette. Done on both medial and lateral side
94	0	0	0	0	Temporary
95	1	628650	-171450	2	Staples
96	1	628650	-171450	2	8 plate
97	1	628650	-171450	2	Transphyseal screw
98	0	0	0	0	Combo
99	0	0	0	0	=========================================
100	0	0	0	0	Histology in distraction histiogenesis?
101	0	228600	-228600	1	Central fibrous interzone: fibroblasts activated and secrete collagen parallel to distraction force. Provides undifferentiated mesenchymal cell which directly transform into osteoblast → intramembranous ossification
102	0	228600	-228600	1	Zone of microcolumn formation: osteoblast aligns collagen to longitudinal column and promotes blood vessel invasion to lay down osteoid
103	0	0	0	0	Factors that affect distraction
104	0	228600	-228600	1	Stability of fixation
105	0	228600	-228600	1	Type and site of osteotomy
106	1	628650	-171450	2	Ilizarov compared 3 different types of osteotomies (open, percutaneous corticotomy, complete closed) recommend percutaneous corticotomy.
107	1	628650	-171450	2	Metaphysis with more osteogenic potential, soft tissue better adapted to lengthening
108	0	228600	-228600	1	Distraction regime
109	1	685800	-228600	2	Latency prior to distraction allows inflammatory phase to subside. Distraction during reparative phase. (3 days for child, 7-14days for adult)
110	1	685800	-228600	2	Rate 1mm/day
111	1	685800	-228600	2	Rhythm – frequency of applying distraction (4 times/day), increase frequency increase distraction
112	0	0	0	0	Complications
113	0	0	0	0	Bone related
114	0	171450	-171450	1	Incomplete consolidation
115	0	171450	-171450	1	Premature consolidation
116	0	171450	-171450	1	Fracture
117	0	171450	-171450	1	Growth disturbance of lengthened bone
118	0	0	0	0	Implant related
119	0	171450	-171450	1	NV injury
120	0	171450	-171450	1	Pin tract infection
121	0	171450	-171450	1	Joint contracture + subluxation

#	semantic level	section?	rewritten line
1	0	yes	Clinical photograph
2	1		Block test
3	1		Right LL shorter by ~5cm
4	1		Both femur and tibia are involved
5	1		Foot and ankle no gross deformity
6	1		No skin stigmata (Café au lait spots in NF in tibial pseudoarthrosis)
7	1		Presence of all 5 toes (fibular hemimelia)
8	0	yes	OVERALL:
9	1		Look for deformity: LLD / angular / rotation
10	0	yes	Cause:
11	1		Hemihypertrophy: Vascular, NF
12	1		Shortening: Neurological, congenital, local (physis)
13	1		Bone age (clinical / radiological)
14	1		Predict LLD (Shapiro + calculations)
15	1		Management plan: conservative / epiphysiodesis / lengthening / amputation
16	1		Cause of LLD
17	0	yes	Long leg:
18	2		Congenital hemihypertrophy (e.g. NF, Klippel Trenaunneay, Beckwidth Wiedemann, Proteus)
19	2		Physeal stimulation (post traumatic)
20	0	yes	Short leg:
21	2		Congenital (DDH, fibular hemimelia, PFFD, calcaneovalgus, enchondromatosis)
22	2		Neuromuscular (polio, cerebral palsy)
23	2		Vascular (Perthes, AV fistula)
24	2		Physis (physis bar, hyperemia): trauma, infection, tumor
25	0	yes	Management:
26	1		Assess cause (from femur/ tibia)
27	1		Assess skeletal maturity (clinical, radiological)
28	1		Calculate LLD at maturity
29	1		Assess function of foot and ankle (joint mobility and stability)
30	1		R/O other deformity (angular, rotational, LL contracture)
31	1		Assess skeletal maturity
32	1		Clinical
33	2		Chronological age
34	2		Tanner staging (1st sign: enlargement of testis, breast bud. Descending phase: menarche/axillary hair)
35	2		Menarche
36	2		Growth spurt
37	1		Radiological
38	1		1. Tanner Whitehouse (With reference to the morphology and fusion of physis in hand and wrist)
39	1		2. Gruelich and Pyle atlas (DP→MC→PP→MP→ulnar→radius)
40	1		3. Risser
41	1		4. Elbow epiphyseal centre (Sauvergain)
42	1		Calculation for LLD at maturity
43	0	yes	Multiple FU:
44	1		1 Moseley chart (need leg length of both LL and Xray hand for skeletal maturity)
45	1		2 Arithmetic method (calculate growth inhibition and predict LLD by future growth in long leg x inhibition)
46	3		Assumption: distal femur 9mm/yr, proximal tibia 6mm/yr, boy stop growth 16, girl 14, Shapiro type 1
47	1		3 Green Anderson chart
48	0	yes	Single FU:
49	1		1 Paley multiplier method (LLD X age and sex factor)
50	1		2 Simplistic
51	1		Also taken into consideration Shapiro’s growth pattern
52	2		LLD proportionally increase: Physeal arrest, PFFD – Most common, static growth inhibition
53	2		LLD growth decelerates: NM conditions
54	2		LLD static after a while: Overgrowth of femur fracture
55	2		LLD static after a while then increase again: Perthes
56	2		LLD plateau and reduce: JRA
57	0	yes	General principles:
58	1		Depends on the LLD at skeletal maturity
59	2		<2cm: observe (manage with shoe raise)
60	2		2-5cm: shorten longer limb by epiphysiodesis if physis open, shortening osteotomy if physis closed
61	2		>5cm: lengthen short limb +/- shorten long limb
62	2		>20cm: consider amputation
63	1		Lengthening techniques (lengthen the short side)
64	0	yes	Acute
65	1		Gradual
66	2		Distraction histiogenesis
67	2		Gradual lengthening procedure by intramembranous ossification, use of distraction force to stimulate the formation of bone and soft tissue
68	2	yes	Procedure:
69	3		Put on exfix
70	3		Perform low energy corticotomy at metaphyseal region (transecting 2/3 of circumference of cortex and complete by osteoclasis by rotating the proximal and distal segment in opposite direction. Preserve the periosteum, endosteum, medullary content and nutrient artery ) OR osteotomy (multiple drill holes followed by completion by osteotome) = no difference in the literature
71	3		Rest for 5-7days
72	3		Gradual distraction (1mm per day divided into 4 times)
73	3		Consolidation ~2x time of lengthening, need Xray to confirm formation of at least 3 cortex
74	3		Removal of exfix when there is closure of interzone and 2 side neocorticalisation on AP and lat films
75	3		Maximum lengthening each time: 20%
76	3		(Michael To tutorial: JPO 2010? % Lengthening related to % of complication, if lengthening >20% → increase complication e.g. nonunion, NV injury, infection, contracture)
77	2	yes	Complication:
78	3		Angular deformity
79	3		Pin tract infection
80	3		Nerve injury (during OT/ traction injury)
81	3		Fracture due to early removal of ex fix
82	2		Chondrodiastasis
83	2		Gradual distraction of physis result in hypertrophy of cellular layers of the physis without separation - Heuter Volkman
84	3		Unpredictable results
85	3		initial lengthening is often followed by growth plate fusion
86	0		Shortening techniques (shorten the long side)
87	0		Permanent
88	1		Open epiphysiodesis (Phiemester)
89	2		Remove rectangular portion of bone containing metaphysis, physis and epiphysis. Flip around and reinsert to create bone bridge
90	2		Adv: predictable outcome
91	2		Disadv: irreversible, long rehab, extensive dissection, angular deformity, exostosis
92	1		Percutaneous epiphysiodesis (Bowen)
93	3		Stab wound. Longitudinal periosteum split + physis penetration 5mm by osteotome. Peripheral 1/3 ablated by curette. Done on both medial and lateral side
94	0		Temporary
95	2		Staples
96	2		8 plate
97	2		Transphyseal screw
98	0		Combo
99	0		——
100	0	yes	Histology in distraction histiogenesis?
101	1		Central fibrous interzone: fibroblasts activated and secrete collagen parallel to distraction force. Provides undifferentiated mesenchymal cell which directly transform into osteoblast → intramembranous ossification
102	1		Zone of microcolumn formation: osteoblast aligns collagen to longitudinal column and promotes blood vessel invasion to lay down osteoid
103	1		Factors that affect distraction
104	1		Stability of fixation
105	0	yes	Type and site of osteotomy
106	2		Ilizarov compared 3 different types of osteotomies (open, percutaneous corticotomy, complete closed) recommend percutaneous corticotomy.
107	2		Metaphysis with more osteogenic potential, soft tissue better adapted to lengthening
108	1		Distraction regime
109	2		Latency prior to distraction allows inflammatory phase to subside. Distraction during reparative phase. (3 days for child, 7-14days for adult)
110	2		Rate 1mm/day
111	2		Rhythm – frequency of applying distraction (4 times/day), increase frequency increase distraction
112	0	yes	Complications
113	1		Bone related
114	1		Incomplete consolidation
115	1		Premature consolidation
116	1		Fracture
117	1		Growth disturbance of lengthened bone
118	1		Implant related
119	1		NV injury
120	1		Pin tract infection
121	1		Joint contracture + subluxation

041. LLD

Clean FRCS notes with inline figures

Clinical photograph

OVERALL:

Cause:

Long leg:

Short leg:

Management:

Multiple FU:

Single FU:

General principles:

Acute

Procedure:

Complication:

Histology in distraction histiogenesis?

Type and site of osteotomy

Complications

Direct Q&A

Block test

Assess cause (from femur/ tibia)

Procedure:

Complication:

Put on exfix

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes