C 30 AnIsomelIa

1. C30 AnIsomelIa

2. Objectives: • What is Anisomelia? • What are the causes? • What are the signs and symptoms?   • How is it diagnosed? • How does imaging play a role in the diagnosis? • What are the different types of treatment? • What are the outcomes?

3. Thesis This presentation will look into the condition Anisomelia and will discuss multiples aspects of the ailment such as causes, signs and symptoms, diagnoses, treatment, and overall outcomes.

4. What is Anisomelia Anisomelia, or more commonly known as Lower Limb Discrepancy (LLD), is a condition in which there is a difference in the lengths of the legs due to congenital or acquired causes1 • Small differences are common • “As many as a 1/3 of the population may have a 1 cm or less discrepancy between their right and left legs”2 • Large differences, however, can be more severe and may have a significant  impact on those affected; they need to be examined and properly treated in order to live comfortably  https://mychart.geisinger.org/staywel/html/Inpatient/3,89068.html

5. CAUSES  Causes of LLD can sometimes be unknown (idiopathic) or can be due to a wide variety of reasons3 • Injury: healing bones can either grow at a faster or slower rate2 • Infection: can damage the growth plates and cause instabilities2 • Neurological Conditions: can create issues with alignment and posture causing a discrepancy2 • Bone Diseases: causes damage to the growth plates over time2 • Bone Tumors: the tumors themselves and their treatments can affect bone growth2

6. SIGNS AND SYMPTOMS  Signs and symptoms will vary patient to patient depending on the size of the difference and the cause3 • Parents will usually detect signs of LLD early on2 • Obvious difference in leg lengths at a young age • Child’s gait while walking differs from peers • Child complains of pain in the lower back and lower extremities https://www.coastalpodiatry.com.au/leg-length-differences/

7. SIGNS AND SYMPTOMS CONT. Symptoms might consist of: • Issues with walking3 • Limp, walking on toes, waddling • Easily tired due to compensation • Low back pain • Hip pain • Knee pain • Postural issues4 https://lermagazine.com/cover_story/assessing-limb-length-discrepenacy

8. DIAGNOSIS • Doctor examination will include a variety of methods in order to properly diagnose LLD • Physical examination • Measurements of the lower legs • Imaging tests

9. DIAGNOSIS – Physical Exam The physical examination will include:  • General health • Medical history • Symptoms • Visual observation of how the child walks, stands, and sits • Gait Analysis – the way the child walks3 • Doctor looks for a noticeable limp, waddling, toe walking, and/or compensation5 http://www.gcmas.org/

10. DIAGNOSIS – Measurement  Tape measure (direct) method: “True” method Measure the distance between the anterior iliac spine (ASIS) and the medial malleolus of the ankle6 • “Apparent” Method • Measure the distance between the umbilicus and medial malleolus of the ankle6 https://boneandspine.com/true-and-apparent-leg-length/

11. DIAGNOSIS – Measurement  Wooden blocks (indirect) method: A series of different height blocks are put under the patient’s shorter leg until the patients hip become even6 • Most accurate way to measure LLD; however, it should be used in conjunction with the direct methods in order to get an overall measurement assessment to attain the most precise limb length difference.6 https://boneandspine.com/true-and-apparent-leg-length/

12. Diagnosis – Imaging Tests • Imaging tests can be used to confirm the LLD measurement and aid in the treatment plan6 • Plain Radiography • Orthoroentogenogram • Scanogram • Teleoroentgenogram • Computed Radiography/Digital Radiography • Microdose Digital Radiography (EOS) • Ultrasound • CT Scanogram • MRI Scan

13. XRAY - Orthoroentogenogram • Three separate exposures are taken over the hip joints, knee joints, and ankle joints6 • Utilizes one long cassette6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/

14. XRAY - Scanogram • Three separate exposures are also taken over the hip, knee, and ankle joints6 • Utilizes one standard sized cassette that is moved after each exposure to that specific joint6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/

15. Modified Scanogram Performed using computed radiography • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/

16. XRAY - Teleoroentgenogram • AP view of both lower limbs fully visualized, sometimes standing6 • Shorter limb will have a wooden block placed under it to even out the pelvis6 • X-ray beam centered at the knee joint6 • Utilizes a longer SID6

17. Full Length ​ Modified Teleoroentgenogram (standing)​ Performed using computed radiography  Modified Teleoroentgenogram (standing)  Performed using computed radiography • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/

18. XRAY - Computed Radiography / digital radiography • Most currently used x-ray methods6 • The same methods that were used for the other x-ray imaging exams can be used when performing a CR and DR imaging exam6 • Three separate exposures are taken over the hip joints, knee joints, and ankle joints, but are then automatically stitched together by the computer software system6

19. Microdose Digital radiography • Also known as EOS imaging  • Reduces patient dose more so than traditional radiography methods6 • Utilizes a vertical gantry with the patient standing directly in front of it6 • A 20 second exposure is utilized with the beam and gantry moving simultaneously6 https://www.chop.edu/treatments/eos-x-ray-imaging-system

20.  https://www.semanticscholar.org/paper/Assessment-of-two-dimensional-(2D)-and-(3D)-lower-Rosskopf-Pfirrmann/aa45759546c9b84d8c484a24273ba68dc7a0ba5d/figure/2text https://www.semanticscholar.org/paper/Assessment-of-two-dimensional-(2D)-and-(3D)-lower-Rosskopf-Pfirrmann/aa45759546c9b84d8c484a24273ba68dc7a0ba5d/figure/2text EOS Imaging

21. Ultrasound  • Utilizes no radiation dose to the patient  • The transducer is used to locate bony landmarks at the hip, knee, and ankle joints6 • Less reliable compared to other methods, but can still be used as an initial screening method6 https://www.hindawi.com/journals/abb/2017/4370649/fig1/

22. CT Scanogram • AP scout view of both femurs and tibias and possibly LAT views6 • Patient lays supine on the table • Measurements of the femur are determined by placing a cursor on the superior aspect of the femoral head and then dragging it down to the distal portion of the medial femoral condyle6 • Measurements of the tibia are determined by placing a cursor on the medial tibial plateau and dragging it down to the tibial plafond6 • Dose is less than traditional radiography and it is more accurate6

23. https://www.researchgate.net/figure/A-CT-scanogram-with-measurement-from-apex-of-femoral-head-to-the-intercondylar-notch_fig11_257222558https://www.researchgate.net/figure/A-CT-scanogram-with-measurement-from-apex-of-femoral-head-to-the-intercondylar-notch_fig11_257222558 Femur measurement Total limb measurement Tibia measurement

24. MRI SCAN • Superior soft tissue imaging, but it can also visualize bony details as well  • Utilizes a T1 weighted spin echo sequence6 • Bony landmarks, such as the femoral head and medial femoral condyle, are used for measurements6 https://www.semanticscholar.org/paper/Magnetic-resonance-imaging-(MRI)-lower-limb-length-Doyle-Winsor/b66b43ae833371717be8070cc4e8e3d155eef560/figure/0

25. TREATMENT Before a treatment plan is decided, the physician, the patient, and the patient’s family have to consider several factors in order to choose the best option: • The magnitude of the discrepancy • 0 cm to 2 cm – No treatment1 • 2 cm to 6 cm – Non-surgical or surgical treatment1 • 5 cm to 20 cm – Intense surgical treatment1 • Greater than 20 cm – Prosthesis1 • The child’s age and state of growth development • Different treatments require a different stage in the growth development7 • The cause of the discrepancy

26. TREATMENT Options Non-Surgical Treatment Methods Surgical Treatment Methods • Shoe lifts  • Prosthetics • Physical Therapy • Observations/Check ups • Leg Shortening Methods • Epiphysiodesis • Epiphyseal stapling  • Bone resection • Leg Lengthening Methods • External fixation  • Internal fixation 

27. Leg shortening surgical methods Epiphysiodesis  • Permanently slows the growth rate in the longer leg to let the shorter leg "catch up" in children who are not done growing7 • The procedure is performed through tiny incisions in the knee area3 • The growth plate is destroyed by drilling or scraping it away3 https://musculoskeletalkey.com/52-epiphysiodesis-of-the-distal-femur-the-green-modification-of-the-phemister-technique/

28. Leg shortening surgical methods  Epiphyseal stapling  • Temporarily slows the rate of growth in the longer leg until the shorter leg "catch's up" in children who are still growing7 • Staples are inserted surgically into each side of the growth plate and are then removed once the legs are of equal length7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686818/

29. Leg shortening surgical methods  Bone resection • Done in patients who are finished growing3 • The doctor removes a section of bone in either the femur or tibia and places metals plates and screws or a rod to hold the bones in place3 • Maximum of 3 in. can be removed in the femur and a maximum of 2 in. can be removed in the tibia3 https://www.reachyourheight.com/limb-lengthening-surgery-treatment-options/surgical-treatment-bone-shortening/

30. Leg Lengthening surgical methods  Internal Fixation  • The shorter leg is cut into two sections and a magnetic motorized nail is inserted between the two pieces of bone7 • After surgery, an external magnet is used to slowly lengthen the shorter leg over time7 https://www.reachyourheight.com/limb-lengthening-surgery-treatment-options/surgical-treatment-precice-internal-lengthening-device/

31. Leg Lengthening surgical methods  External Fixation  • The shorter leg is cut into two sections, then an external fixator is put into place, the bones and external fixator are held together by pins7 • After surgery, the external fixator is slightly adjusted each day to lengthen the leg creating new born formation between the two original bones7 • The external fixator will eventually be removed once the desired length is acquired7 https://www.reachyourheight.com/limb-lengthening-surgery-treatment-options/surgical-treatment-external-fixation/

32. OUTCOMES • If treated, there is a positive prognosis  • The child will not have any activity restrictions  • Quality of life will be overall improved • If not treated, this ailment could have negative impacts • Child could experience back, hip, and leg pain • Might walk with a limp or have other issues with their gait • May adversely affect self image • Possible activity restrictions

33. Time to Test your knowledge with flash cards Before clicking on the flash card make sure to think of the correct answer

34. Physical examination, measurements, imaging exam(s) What does the diagnosis typically consist of? What is Epiphysiodesis? The growth plate is destroyed by scraping it away The dose is less than other modalities and measurements are more accurate: CT Anisomelia What is the medical term for Lower Limb Discrepancy External fixator What is a bone lengthening surgical method? Hip, knee, and ankle joints Which joints are imaged for radiography methods? Examples of non-surgical methods: Shoe lift, prosthetic, physical therapy, continuous checkups MRI and US What imaging methods don’t utilize any radiation? Wooden blocks and tape measure Two main ways to measure LLD: What are some causes of LLD? Injury, infection, tumors, neurological conditions, disease Are epiphyseal staples ever removed? Yes Who usually detects LLD? Parents

35. Conclusion Minor leg length discrepancies can be common; however, Anisomelia, which is a noticeable leg length discrepancy, can have negative impacts on the child's health and quality of life. There are numerous imaging methods used in the diagnosis of Anisomelia. Of these methods, some involve radiation, as with x-ray imaging and CT imaging. Conversely, there are some low to no dose options available such as EOS, MRI, and ultrasound. Ultimately, the method of imaging used for diagnosis is up to the patient/parents and the their physician. No matter what form of imaging and treatment is chosen for the child, the most important factor is getting a proper diagnoses and treatment method that will benefit the child's overall health and well-being.

36. References • 1. Quinones D, Liu R, Gebhart JJ. Leg Length Discrepancy (LLD). POSNA. https://posna.org/Physician-Education/Study-Guide/Leg-Length-Discrepancy. Accessed March 2, 2019. • 2. Children's Hospital. Limb-length Discrepancy. Children's Hospital of Philadelphia. https://www.chop.edu/conditions-diseases/limb-length-discrepancy. Published May 20, 2017. Accessed March 2, 2019. • 3. Our knowledge of orthopaedics. Your best health. Frozen Shoulder - Adhesive Capsulitis - OrthoInfo - AAOS. https://orthoinfo.aaos.org/en/diseases--conditions/limb-length-discrepancy/. Published May 2016. Accessed March 2, 2019. • 4. Leg Length Discrepancy | Symptoms and Causes | Boston Children's Hospital. Boston Childrens Hospital. http://www.childrenshospital.org/conditions-and-treatments/conditions/l/leg-length-discrepancy/symptoms-and-causes. Accessed March 2, 2019. • 5. Leg Length Discrepancy in Children | Diagnosis | Boston Children's Hospital. Boston Childrens Hospital. http://www.childrenshospital.org/conditions-and-treatments/conditions/l/leg-length-discrepancy/diagnosis. Accessed March 8, 2019. •  6. Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. ClinOrthopRelat Res. 2008;466(12):2910-22. •  7. Leg Length Discrepancy in Children | Treatment | Boston Children's Hospital. Boston Childrens Hospital. http://www.childrenshospital.org/conditions-and-treatments/conditions/l/leg-length-discrepancy/treatments. Accessed March 8, 2019.