Management for the long limb.
Is there a role for amputation?
Amy L. McIntosh MD
Pediatric Orthopedic Surgeon
CP1013403-1
Limb Hypertrophy
• Soft tissue and
•
or bone
enlargement
Extremities
Lower (nearly
all)
Upper
Pelvis and
Thorax
Evaluation
• History
• Examination
• Imaging
Radiographs
Bone age
Scanogram
CP1013403-2
Phyiscal Examination
• Assess LLD w/ pt.
standing
• Add blocks
(known height)
until the pelvis is
level
1 inch
Radiographs (Bone Age)
• A film of the left
hand
• Compared to a book
of radiographs of
children’s hands of
known ages
• Gives an estimate of
bone maturity 
growth remaining
Radiographs (Measure Length
Discrepancy)
• Telorengenogram
• Orthoroentgenogram
• Scanogram (x-ray/ CT)
TELEO
Length of x-ray shadow
CP1013403-4
CP1013403-5
ORTHO
A
A
a
a
b
A
c
Length of x-ray shadow
a
d
CP1013403-6
CP1013403-7
SCANO
Roentgen ray tube
Direction of motion
Slit diaphragm
Slit-like roentgen
ray beam
Cassette
CP1013403-8
CP1013403-9
Leg-Length Discrepancy
Guidelines for Management
Discrepancy
Management
(CM)
<2
No treatment or shoe lift
2-5
Growth Modulation
5-12.5
Consider bone-lengthening
>12.5
Combinations of above or
amputation
LIMB LENGTH DISCREPANCY
Prediction Methods
I. Rule of thumb Westh and Menelaus (1981)
II. Growth remaining Anderson and Green
(1963)
III. Striaght line Moseley (1978)
IV. Paley Multiplier Method (2000)
Theres an APP for that!!
Leg-Length Discrepancy
Guidelines for Management
Discrepancy
Management
(CM)
<2
No treatment or shoe lift
2-5
Growth Modulation
5-12.5
Consider bone-lengthening
>12.5
Combinations of above or
amputation
Growth Modulation
• Epiphysiodesis: (kill
the growth plate)
• Eight Plates (squeeze
the growth plate)
Open Epiphysiodesis
Percutaneous Epiphysiodesis
Screw Epiphysiodesis
Eight Plates
Leg-Length Discrepancy
Guidelines for Management
Discrepancy
Management
(CM)
<2
No treatment or shoe lift
2-5
Growth Modulation
5-12.5
Consider bone-lengthening
>12.5
Combinations of above or
amputation
Leg-Length Discrepancy
Guidelines for Management
Discrepancy
Management
(CM)
<2
No treatment or shoe lift
2-5
Growth Modulation
5-12.5
Consider bone-lengthening
>12.5
Combinations of above or
amputation
Is there a role for amputation??
• Yes!!!
• Significant length discrepancy
• Poor underlying bone quality for
lengthening
• Dysfunctional/ painful limb
CT angiogram
MRI
femur
Klippel Tenaunay Syndrome
• Preoperative labs:
• Hemoglobin 10.8 g/dL, Hematocrit 35.8%,
Platelets 98 x 109 /L
• INR 1.4, Prothrombin time 13.0 seconds,
D-Dimer >2000 ng/mL
• Creatinine 0.5
• Kasabach-Merritt Syndrome
Klippel Tenaunay Syndrome
• Intraoperative (June 21, 2010):
Anterior flap fashion with plastic surgery
• Vascular surgery present for hemostasis control numerous vascular channels despite use of
tourniquet
Patient became unstable – procedure stopped at
transfemoral amputation
Fluid status
Estimated blood loss: 5.7 liters
Fluids: 8 units FFP, 4 units Cryo, 2 units
PRBC, 11 units cell saver, 1 pack platelet,
1500 cc albumin, 5,400 cc crystalloid
July 2, 2010
Klippel Tenaunay Syndrome
– July 5, 2010 – increasing pain and requirement of blood
products. Returned to OR with vascular surgery
• EBL 22.7L, Received 59.7L resuscitation: 24L
pRBCs, 18L FFP, 1.8L platelets, 1.6L cryo, 3 VII
Factor
July 29, 2010
August 12, 2010
August 5, 2010
August 20, 2010
September 13, 2010
Present day