Limb Length Discrepancy and Angular Deformity due to Benign Bone Tumors and Tumor-like Lesions

Abstract

Benign bone tumors and tumor-like lesions are frequently diagnosed in children and adolescents. The immature skeleton is at risk for growth disturbances and deformity because of the effects of the lesions on normal bone architecture and the physis. The development, manifestation, and severity of the limb length inequality and deformity differs between the various bone pathologies. Distraction osteogenesis, osteotomy, and guided growth are key tools in the treatment of limb inequality and deformity using a combination of external and internal fixation devices.

Figure 1

A, Figure demonstrating a patient with Ollier disease who underwent one humeral lengthening 5 years ago but has residual limb length discrepancy and limited growth potential remaining. B, Concurrent proximal humeral procurvatum deformity present. C and D, A monolateral rail was used to lengthen the bone and correct the deformity. E and F, After consolidation of new bone the rail is removed, and the deformity has been corrected and humerus lengthened.

Figure 2

A, Figure demonstrating a patient with multiple hereditary exostosis who presented with gross deformity of forearm. The bone lengths are equal, but the radial bow is increased, leading to ulnar translocation of carpus (measurements originally described by Burgess et al). B, Although the radial head did not dislocate during growth in this patient, subluxation is evident (yellow arrow). C and D, External fixator used to lengthen the ulna (green arrow) and correct the radial deformity (yellow arrow). E and F, Radiographs of forearm after fixator removal demonstrating improved position of carpus and radial head.

Figure 3

A, Figure demonstrating a patient with multiple hereditary exostosis presented with right leg length discrepancy of 22 mm and distal femur valgus deformity. B, Guided growth was successful in treating the distal femoral valgus, but bilateral proximal tibia valgus developed demonstrated by medial proximal tibia angle >90°. C, The proximal tibial valgus persisted despite 18 months of guided growth. A lengthening of the femur to correct the limb length discrepancy was also done during this time. D, Bilateral tibial osteotomies were used to correct the tibial valgus. Note the blocking screws proximal to the osteotomies to guide the path of the nails. Mechanical axis lines now pass through the center of the knees.

Figure 4

A, Figure demonstrating a patient with a history of proximal humerus unicameral bone cyst, now involuted with residual varus deformity. B, The humerus is short versus the contralateral which measured 300 mm; also with procurvatum deformity. C, An internal lengthening humeral nail was used to correct the deformity and lengthen the humerus; the nail has been distracted 48 mm. D, After consolidation of the new bone the nail is removed and the deformity has been corrected. E, The arm lengths have been equalized

Figure 5

A, Figure demonstrating a patient with history of fibrous dysplasia and right proximal femur stabilization presented with pain in right hip and knee along with 1 inch leg length discrepancy (block under right foot). B, Despite previous surgery as a child, the fibrous dysplasia lesion is at ongoing risk of pathologic fracture. C, The lesion was bypassed and stabilized with an internal lengthening nail which corrected the limb length discrepancy via distraction osteogenesis. D, The lengthening nail was exchanged for a static locked nail to provide ongoing support of the pathologic bone.