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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 55-58

Lengthening for functional acetabular dysplasia due to limb length discrepancy: A report of two cases


Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan

Date of Web Publication17-May-2016

Correspondence Address:
Hidenori Matsubara
Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8641
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3719.182577

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  Abstract 

Osteoarthritis of the hip joint as a complication of limb length discrepancy (LLD) caused by lower extremity deformity is rarely reported in the literature. We report two such cases of osteoarthritic changes of the long leg hip joint due to severe LLD but no developmental dysplasia of the hip. Both underwent limb lengthening, and the symptoms were improved without further treatment. The osteoarthritic changes are secondary to functional acetabular dysplasia resulting in insufficient acetabular coverage of the femoral head and lateral inclination of the pelvis caused by LLD. Thus, lengthening treatment may be one option for such patients with osteoarthritis due to functional acetabular dysplasia.

Keywords: Functional acetabular dysplasia, limb lengthening, osteoarthritis of the hip joint, pelvic inclination


How to cite this article:
Yoshida Y, Matsubara H, Takata M, Aikawa T, Shimbashi S, Ugaji S, Tsuchiya H. Lengthening for functional acetabular dysplasia due to limb length discrepancy: A report of two cases . J Limb Lengthen Reconstr 2016;2:55-8

How to cite this URL:
Yoshida Y, Matsubara H, Takata M, Aikawa T, Shimbashi S, Ugaji S, Tsuchiya H. Lengthening for functional acetabular dysplasia due to limb length discrepancy: A report of two cases . J Limb Lengthen Reconstr [serial online] 2016 [cited 2019 May 20];2:55-8. Available from: http://www.jlimblengthrecon.org/text.asp?2016/2/1/55/182577


  Introduction Top


Limb length discrepancy (LLD) can be caused by congenital, posttraumatic and postinfective etiologies and tumors, etc., Severe LLD causes limp, scoliosis, and osteoarthritis of the knee and/or ankle and decreases the quality of life. Generally, these secondary problems can occur with an LLD of 2 cm or more warranting surgical treatment. [1],[2],[3] However, little is known concerning osteoarthritis of the hip joint as a complication of such LLD. We report two cases of long leg hip osteoarthritis associated with functional acetabular dysplasia caused by LLD but no developmental dysplasia of the hip (DDH).


  Case Reports Top


Case 1

A 31-year-old woman presented with a chief complaint of left hip joint pain. She had Klippel-Trenaunay-Weber syndrome, hypertrophy of the left leg, and LLD from childhood. She was referred to us for left coxalgia that developed at 30 years of age. Physical examination revealed hypertrophy of the left leg, a tender and swollen left hip joint, and LLD of about 4.5 cm. Venous varicosities were present all over the left leg, and a hemangioma (3 cm in diameter) was noted on the dorsum of her left foot [Figure 1]. The affected hip joint was tender and swollen, and the range of motion was limited. Radiographs revealed that the lengths of the right and left legs were 65 and 69 cm, respectively. The mechanical axes of the legs passed through the centers of the knees. In the standing position, the left hip joint inclined to the right side, with a center-edge angle of 15° that reduced the acetabular coverage of the femoral head [Figure 2]a]. The inclination of the pelvis induced reversible scoliosis. End-stage osteoarthritic changes such as cystic changes at the acetabulum and narrowing of the joint space were noted in her left hip joint. A foot lift of 4 cm on the right side made the pelvis horizontal and the center-edge angle improved to 33° with no evident acetabular dysplasia [Figure 2]b. Lengthening of the right tibia was performed using a Taylor spatial frame (TSF). The lengthening period was 107 days, and the external fixator was applied for 750 days until bone union. The lengthening achieved was 4 cm; the distraction index was 26.8 days/cm, and the external fixation index was 187.5 days/cm. With correction of the LLD, the center-edge angle improved to 35° [Figure 2]c, and scoliosis improved by straightening of the spine. In addition, the joint space was more apparent than at initial diagnosis and maintained at 10-year follow-up [Figure 3]. The hip joint pain had disappeared and arthroplasty was avoided. Japanese Orthopaedic Association (JOA) hip score [4] improved from preoperative 51 to 96 points at the final visit of 10-year follow-up [Table 1].
Figure 1: (a) Hypertrophy of the left leg and limb length discrepancy, (b) venous varicosities on the left lower limb, and (c) a hemangioma (3 cm in diameter) on the dorsum of the foot

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Figure 2: (a) Leg length discrepancy causing a 15° pelvic inclination in the standing position. (b) The center-edge angle improved from 15° to 33° with a 4 cm foot lift on the right side. (c) It improved to 35° after lengthening

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Figure 3: (a) Before the operation, (b) 5 years after the operation, and (c) 10 years after the operation. The joint space was more apparent than at initial diagnosis and maintained until the 10-year follow-up

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Table 1: The Japanese Orthopaedic Association clinical score of the two cases


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Case 2

A 39-year-old man had shortening deformity of the left leg due to hereditary multiple exostosis and the several surgeries. He visited us with the pain of the unaffected right hip joint. His left femur radiographs showed varus deformity of 17° in the anteroposterior view, procurvatum deformity of 20° in the lateral view [Figure 4]a and b, and lateral inclination of the pelvis in the standing position [Figure 5]a. The LLD was 4.5 cm when compared with the normal side. The right center-edge angle was 15°. However, after a 4.5 cm left foot lift, the center-edge angle improved to 32°, and no acetabular dysplasia was evident. The patient also had compensatory scoliosis. Correction of the deformity and lengthening of the left femur were performed using the TSF to achieve the limb length equalization. The radiograph taken at the completion of correction and lengthening showed good callus formation [Figure 4]c. The TSF was applied for 61 days until the plate conversion surgery. Correction of the pelvis inclination resulted in relief from the hip pain and correction of scoliosis. On follow-up after 21 months, the preoperative LLD was solved and the final radiographs revealed that the lengths of the right and left legs were 81.5 and 80.7 cm, respectively [Figure 6]. The center-edge angle had improved to 30° [Figure 5]b]. JOA hip score improved from 80 points to perfect 100 points, preoperative and postoperative, respectively [Table 1].
Figure 4: Preoperative (a) anteroposterior and (b) lateral view. (c) After correction and lengthening

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Figure 5: (a) Before the operation, and (b) 21 months after the operation

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Figure 6: The final radiographs (21 months after the application of Taylor spatial frame)

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  Discussion Top


Acetabular dysplasia and DDH are considered as risk factors for osteoarthritis of the hip joint, [5],[6] also almost same as epidemiological data in Japan. Our two patients had no history of DDH and did not show acetabular dysplasia with the use of foot lifts. However, both had severe LLD (exceeding 4 cm) due to pathological conditions, and compensatory lateral inclination of the pelvis was observed. Osteoarthritis of the hip joint can result from kyphosis due to degenerative lumbar spondylosis in middle-aged and older individuals. This may cause the pelvis to develop a backward incline, thus decreasing the anterior coverage of the femoral head in the standing position, without morphological abnormality of the hip joint. [7],[8],[9] We propose that the hip joint symptoms may occur by the above mechanisms such as lateral inclination of the pelvis leading to functional acetabular dysplasia in which femoral head coverage by the lateral part of the acetabular roof decreases on the side of the longer limb. Consequently, hip osteoarthritis can be regarded as another issue attributable to LLD, in addition to problems such as limping gait, scoliosis, and knee or ankle osteoarthritis.

Surgical treatments for hip osteoarthritis generally include total hip replacement (THR), joint-preserving surgery such as osteotomy, and hip arthrodesis. Especially in our Case 1 patient, she was considered an indication for THR because she had osteoarthritic changes at the end stage (as observed on the radiographs) without acetabular dysplasia. However, the coxalgia was improved only by correction of severe LLD and unnecessary surgeries such as THR could be avoided. In fact, JOA hip score was significantly improved after surgery and remained high to date in each case. Of course, further evaluation and follow-up of such cases are necessary.


  Conclusion Top


We report two cases in patients with osteoarthritic changes of the hip joint, caused by severe LLD associated with functional acetabular dysplasia of the hip. Both patients were treated only with limb lengthening, and symptoms improved without further treatment. Lengthening treatment may be an option for such patients with osteoarthritis due to functional acetabular dysplasia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE, et al. Association of leg-length inequality with knee osteoarthritis: A cohort study. Ann Intern Med 2010;152:287-95.  Back to cited text no. 1
    
2.
Mishima K, Kitoh H, Kadono I, Matsushita M, Sugiura H, Hasegawa S, et al. Prediction of clinically significant leg-length discrepancy in congenital disorders. Orthopedics 2015;38:e919-24.  Back to cited text no. 2
    
3.
Kendall JC, Bird AR, Azari MF. Foot posture, leg length discrepancy and low back pain - Their relationship and clinical management using foot orthoses - An overview. Foot (Edinb) 2014;24:75-80.  Back to cited text no. 3
    
4.
Kuribayashi M, Takahashi KA, Fujioka M, Ueshima K, Inoue S, Kubo T. Reliability and validity of the Japanese Orthopaedic Association hip score. J Orthop Sci 2010;15:452-8.  Back to cited text no. 4
    
5.
Albinana J, Dolan LA, Spratt KF, Morcuende J, Meyer MD, Weinstein SL. Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures. J Bone Joint Surg Br 2004;86:876-86.  Back to cited text no. 5
    
6.
Jacobsen S, Sonne-Holm S, Søballe K, Gebuhr P, Lund B. Hip dysplasia and osteoarthrosis: A survey of 4151 subjects from the Osteoarthrosis Substudy of the Copenhagen City Heart Study. Acta Orthop 2005;76:149-58.  Back to cited text no. 6
    
7.
Offierski CM, MacNab I. Hip-spine syndrome. Spine (Phila Pa 1976) 1983;8:316-21.  Back to cited text no. 7
    
8.
Yoshimoto H, Sato S, Masuda T, Kanno T, Shundo M, Hyakumachi T, et al. Spinopelvic alignment in patients with osteoarthrosis of the hip: A radiographic comparison to patients with low back pain. Spine (Phila Pa 1976) 2005;30:1650-7.  Back to cited text no. 8
    
9.
Devin CJ, McCullough KA, Morris BJ, Yates AJ, Kang JD. Hip-spine syndrome. J Am Acad Orthop Surg 2012;20:434-42.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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