scoliosis and lld

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1982;64:59-62.J Bone Joint Surg Am.T Papaioannou, I Stokes and J Kenwright Scoliosis associated with limb-length inequality

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Copyright 1982 by Th e Jou rna l o f B on e an d Jo in t S u rge ry, In corpora ted

VOL . 6 4-A , NO . I , JAN UARY 1982 59

Sco lio s is A sso cia ted w ith L im b -L eng th In equa lityBY T . PAPAIOANNOU , M .D .* , STOKES , PH .D .t, A ND J . K ENW RIGHT , M .A ., M .D ., F .R .C .S .* ,

OXFORD, ENGLAND

F rom the N u ffie ld O rthopaed ic Centre and O rthopaed ic Eng ineering Centre , O xfo rd

ABSTRACT : W e review ed the record s and phys ica lfind ing s of tw en ty -th ree young adu lts who had hadsign if ican t un treated lim b -length in equality , p resen tsin ce ch ildhood . T he sp in e w as stud ied rad iograph i-ca lly and clin ica lly b efore and a fter neu tra liza tion o fth e d iscrepancy of lim b length s w ith a lift . M ovem en tsof th e sp in e a lso w ere m easured .

A sign if ican t a symm etry of la tera l fiex ion of th esp in e rem ain ed in near ly a ll o f th e patien ts a fter n eu -tra liza tion o f th e d iscrepancy . T he lum bar sco lios is as -so cia ted w ith th e lim b -leng th in equality w as com pen sa-to ry and non -prog ressiv e, bu t abnorm alit ie s o f th eC obb ang le and of ax ia l rotation rem ained in the youngadults.

N o re la tionsh ip w as fou nd be tw een th e under ly ingcau se of th e an isom elia o r its duration and the sev er ityof th e sp ina l abnorm ality . T he sco liosis w as m ino r inpatien ts w ith d iscrepanc ies ofle ss than 2 .2 cen tim eters.N o pa tien ts com pla ined o f sign if ican t d is com fort in th eback , nor w ere deg enerative rad iograph ic changes ev i-d en t th ere .

T he p atte rn o f sco lio s is a ssoc ia ted w ith lim b-len g thineq ua lity (an isom e lia ) usua lly is desc r ibed as b ein g com -pensa to ry , non -struc tu ra l, and non-p rogressive46 . In1964 , h ow ev er , S che ller w as o f the op in ion tha tan isom elia cou ld prod uce s truc tu ra l changes in the sp inew ith tim e, an d m any o f th e pa tien ts w hom he investig atedw ere exp erienc ing b ack pa in .

P rev iou s stud ie s o f the sco lio sis a ssoc ia ted w ithan isom e lia alw ays have been qua lita tive and it is no tkn ow n p rec isely w ha t e ffec t neu traliza tion of th e lim b-leng th d is crepancy has on th e sp in e. T ha t know led gem ig h t be u se fu l if a d ec isio n is to be m ade on the am oun to f op e ra tive o r n on-op era tive co rrec tion th at is d es irab le o ro n w hen to p erfo rm an op era tion fo r co rrec tio n .In the p re sen t pape r w e a re reporting o ur stud ie s o n agroup of yo ung ad u lts w ho had a sign if ican t deg ree o f u n-trea ted an isom elia tha t had b een presen t since ch ildh ood .W e asked th e fo llow ing qu estio ns:

1 . Is th ere just o ne p atte rn o f sco lio sis a sso cia tedw ith an isom e lia? A re the re irreve rsib le struc tu ral ch an ges

* N uffie ld O rtho paed ic C entre , H eading ton , O xfo rd O X3 7LD ,England .

t D epa rtm en t of O rtho paed ic Su rge ry , U n ive rsity of V erm on t,G iven B uild in g , Bu rlin g to n , V e rm ont 0 5405 .

tha t o ccu r w ith in the sp in e tha t m igh t p red isp ose to th e de -v elo pm en t o f back pa in?

2 . If th e p elv is is leve led w hen the pa tien t is an ad u lt,w ill the re be re sidua l sp ina l d efo rm ity?

3 . W hat ran ge of late ral bend ing m ovem en t o f thesp ine can b e exp ec ted afte r n eu tra lizatio n o f th e lim b-le ng th d isc re pa nc y?

4 . A re the re co rre latio ns b etw een the sco lio s is an dthe cause o f the an isom elia o r its m agn itud e?

Mate r ia lTw en ty -th ree pa tien ts w ere seen w ith an isom e lia

rang in g from 1 . 2 to 5 .2 c e nt im e te rs . The d isc repancy hadb een p re sen t th roug h a la rg e p art o f the pa tien ts ch ild -h ood s. P atien ts w ere exc lud ed if the p rim ary e tio lo gy ofthe d is crepancy w as po liom ye litis o r ano th er n eu rom uscu -la r d iso rde r tha t m igh t in c lude a m u sc le w eaknessin f luenc in g the shape of th e sp ine . T he und erly in g d isea se sin the tw en ty -th ree pa tien ts w ere: hem ihy pe rtrop hy (n in ep atien ts) ; con gen ita l sho rten ing (fo u r p atien ts ); p rev iou sfrac tu re (th ree p a tien ts); hem ia tro phy (tw o pa tien ts) ; andjo in t in fec tion , rad iatio n in ju ry , con gen ita l d is locatio n o fthe h ip , ove rg row th du e to K lippe l-T ren au nay sy ndrom e ,and congen ita l co nstr ictio n bands (o ne pa tien t each ). Theages o f th e pa tien ts a t th e tim e o f exam ina tion rang ed fromseven teen to th ir ty -n ine yea rs (m ean , tw en ty -e igh t years) T he re w ere tw e lve m a le and e leven fem a le pa tien ts .

M ethod s o f S tudyR ad io g ra p h ic A sse ssm en t

S tand in g an te ropo ster io r rad iog raphs o f each pa tien tw ere m ade , firs t w ith the pa tien t b a re fo o t w ith bo th h ee lson the flo o r an d w ith bo th k nees ex tend ed . Th e casse ttew as p laced beh in d a shee t o f m e thy lm e thacry la te w ith ac -cu ra te ly a ligned ho rizon tal and v ertical s tee l w ire s set in toits su rface . Th ese w ire s p rov ided a horizo n ta l and a ve rti-ca l re fe ren ce o n each rad iog raph . Th e rad io g rap h w as 3 50by 430 m illim e te rs in size and sh ow ed the po sition s o f thefem o ra l heads, the ilia c c res ts , an d m o st o f theth o raco lum bar sp in e . The d istan ce from the h orizo n ta lre fe ren ce line to each fem oral h ead w as m easu red fromth is rad iog raph . T he tub e-to -film d is tan ce fo r th ese rad io -g rap hs w as on e m ete r . T h e po sition in w hich the p atien ts tood w as such tha t the fem o ra l h eads w ere ap pro x im a te lytw en ty cen tim e ters from the p lan e of th e film , w h ich g av ea m agn if icatio n fac to r o f 20 pe r cen t. A fte r co rrec tion fo r


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COBBANGLE C o b b L . :

2 .0 x 5 a c r um/

to rightTILT ANGLE

I rightI concave

F I G . IRelatio nship betw een the til t o f the sac rum to the horizontal and the

Cobb angle befo re limb-leng th corre ction. The slo pe of the regress ion lineis 1 .6 1 . In this graph allow ance is made for the s ide o f the l imb-leng th dis -e repaney and the dire ctio n of the curve o f the o verly ing seo lio sis .

60 T . PA PA I O ANNO U , I . ST OK ES, A ND J. K ENW R I G H T

THE JOURNAL OF BONE AND JOINT SURGERY

magnif icatio n, w e calculated the limb-length inequality incentimeters . The beam w as centered at the leve l o f the fifthlum bar ve rte bra.

A second radiog raph w as made under identical con-ditions, w ith the patient standing as w ith the first, ex ceptthat a w ooden blo ck w as placed under one fo ot. The thick-nes s o f the block w as cho sen to neutralize the limb-lengthinequality w hich w as calculated from the first radio graph.The x -ray beam w as raised six ty m illim eters and the beamw as coned in order to m inim ize gonadal irradiation. B e -fore making the radiog raph the patient w as allow ed severalm inutes to achieve a comfo rtable po sition. Three patientscould no t achieve such a positio n after co rrectio n o f limblength and they sto od uncomfortably , in a manner that didnot satisfy the conditions for radiog raphic measurement.Thus, no data are presented fo r the findings after correc -tion o f limb length in these three patients .

The fo llow ing m easurements w ere made from the tw oradio graphs w ith the horizontal as the re ference line.

Angles to the horizontal: A line w as draw n throughthe superior articular surfaces o f the tw o femoral heads;another w as drawn along the prox imal marg ins o f the tw oiliac crests; and a third w as draw n along the upper surfaceo f the sacrum . These three lines de fined the extent o f pel-v ic obliquity . There w as a high corre lation be tw een theang le fo rm ed by the ho rizontal and the line draw n alongthe femoral heads (representing limb-length discrepancy)and the ang le o f the sacral tilt (r = 0 .9 8 ) . These ang le sw ere the same w ithin a lim it o f accuracy of measurem ent( 2 .5 per cent) , and the ang le formed by the line draw nalong the iliac crests also co rrelated w ell w ith the femoralhead ang le (r = 0 .99 ) . Thus, there w as no ev idence ofsignificant pe lv ic asymmetry in the patients w ho w erestudied.

Cobb angle ofthe spine : This w as measured and theupper and low er vertebrae used in this m easurement w ererecorded.

Axial rotation ofthe vertebrae: This w as m easured atmultiple leve ls 2,7

The c linical ranges o f lateral bending to the right andto the left w ere 6 and expressed in deg rees foreach side as the patient bent maximally to the right and tothe le ft in turn . The approx imation and separation of marksthat had been made on the skin w ere m easured6 A cone-lation (r = 0 .5 , p < 0 .1 ) w ith a one-to -one re lationshipw as found betw een the m easurements o f lateral bendingobtained from the approx imation of the marks and thoseobtained from the separation of the skin marks. There fore,the mean of the tw o values w as used in the subsequentanalysis o f ranges o f movem ent.

ResultsWhen the patients w ere standing w ithout the blo ck

under the sho rt limb the expec ted lateral curve of thespine , convex tow ard the short limb, w as seen in all pa-tients and the first sacral segm ent alw ays w as the low estaffec ted vertebra. The firs t lumbar vertebra w as the up-

permost leve l o f invo lv em ent in ev ery patient except one ,in whom the curve ex tended to the eleventh thoracic ver-tebra.

CobbLi . 6 lxS oc r umL

F I G . 2Lumbar seo liosis asso ciated w ith uncorre cted limb-leng th discrepancy .

The Cobb ang le is less than the ang le o f sacral tilt, so that the upper v er-tebra of the compensato ry lumbar curve is not ve rtic ally above the saeralbody .


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I I

D is cre pa nc y in m m Ag eS i 24S I 1 73 0 II36 2327 2246 264 6 28

.4 4 6 3040 3933 2912 3615 3218 2322 3612 2622 342 0 3018 2822 3215 36

5 1 O

F I G . 3The Cobb angles (abscissa) before and after limb-length correction for each patient. T he number of mill imeters of limb-length discrepancy before

neutralization and the age of the patient in years are recorded alongside (see text for a description of the three patients who were excluded) .

F I G . 4-A F I G . 4-BFig. 4-A : L umbar seoliosis in a patient w ith 3.3 centimeters of shortening of the lef t l imb.Fig. 4-B : Correction of the compensatory lumbar curve with limb-length equalization. Note that the upper portion of the spine becomes decompensated.

SC O L IO S IS A SSO C IA T E D W IT H L IM B -L E NG T H INE Q UAL IT Y 61

VO L . 6 4-A , N O . 1 , J A NUAR Y 1982

3 5 3 0

A b so Lu te V al ueo f C o b b A ng Le( D e g r e e s )

20 15 10 5 0, .4C o b b Ang Le C o b b Ang l eb e fo re p e lv ic a fte r p e L v i cLe v e LLin g Le v e lling

The Cobb angle varied in proportion to the severity ofthe anisomelia. There also was a close relationship be-tween the Cobb angle and the angle of sacral tilt (Fig. 1),the ratio being 1 .6: 1 . In a patient w ith a fully compensatedand balanced scoliosis, the occiput w ill be vertically abovethe sacrum and the ratio of the Cobb angle to the angle ofsacral tilt w ill be 2: 1 . The ratio of 1 .6: 1 seen in our pa-tients reflects a lack of complete balance in the spine and isindicative of undercorrection of the compensatoryscoliosis. This undercorrection also was seen as a devia-tion of the mid-point of the uppermost vertebra of thecompensatory lumbar curve from the midline (Fig. 2).

W hen the pelvis was made level by placing the properblock under the short limb, the spine did not become

completely straight in our patients. T he Cobb angles (Fig.3) revealed that in six patients there was a small residuallumbar curve (4 to 8 degrees) in the initial direction. Inseven patients, there was a reversal of the lumbar scoliosisof 3 to 10 degrees. I n eight patients, although there was agood correction of the Cobb angle of the lumbar curve onneutralization of the anisomelia, some abnormality re-mained in the spine above the lumbar region. I n these pa-tients the upper part of the spine was decompensated, tilt-ing toward the previously short limb but w ith minimumlumbar scoliosis (Figs. 4-A and 4-B).

T here was a close correlation between the mea-surements of axial rotation obtained by the two methodsused, and there was a very variable relationship between


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62 T . P A PA IO ANNO U , I . ST O K E S , A ND J . K E NW R IG H T the Cobb ang le and the degree of ro tation . A r o t a to r y a b -no rmality w as seen in nearly all patients be fore neutraliza-tion of the anisom elia. The maximum ro tatio n usually oc -curred in the low er lumbar leve ls . In six teen patients therew as ax ial ro tation of zero to S deg rees; in six , o f 6 to 1 0degrees; and in one , o f 17 degrees . The mean ax ial ro ta-tion prior to limb-length correc tion w as 4 .39 3 .66 de -grees . There w as a small , persistent degree of ax ial ro ta-tion after the pelv is w as made leve l in e ight patients , but inonly one w as it m ore than 10 degrees (mean ax ial ro tation,3 .60 2 .57 de gre es ).

D egenerativ e changes in the face ts or disc spaces o fthe lumbar spine w ere not seen on the radio graphs of anypatients . N o patients complained of pain in the back e itherduring or be fo re the te st.

There w as cons iderable asymmetry o f lateral bendingin all o f the patients , consisting of a reduction o f lateralbend to the side of the concav ity o f the curve comparedw ith bending the other w ay (mean bend to the concav eside, 23 .7 7 .43 deg rees; m ean bend to the convex side,34 .4 7 .67 deg rees). The decreased amplitude o f bend-ing correlated s trong ly w ith the size o f the limb-lengthdiscrepancy (r = 0 .83 , p < 0 .0 01) , and is to be expectedin patients w ith compensatory sco lio sis . A fter neutraliz ingthe anisomelia, and thus correc ting fo r the sco lio s is , therestill w as considerable asymmetry of mov em ent. There re -mained a reduced rang e o f lateral f lex ion tow ard the prev i-ously convex side o f the lumbar curve (mean bend to theconcave side , 40 . 1 5 9 . 16 degrees; mean bend to theconv ex side , 17 . 15 8 .50 de gre es) .

There w ere no c lear-cut corre latio ns be tw een theradiog raphic o r c linical observ atio ns recorded and thee tio log y o f the anisomelia.

There w as a good corre latio n betw een the degree o fanisomelia and the amount o f residual sco lio sis w hen theanisomelia w as neutralized. Patients w ith le ss than 2 .2centimeters o f limb-length discrepancy show ed a v erysmall re sidual sco lio s is w hen a lift o f appropriate thicknessw as used under the short ex trem ity .

Discu s s io nOnly young adults w ere cho sen fo r the inv estig atio n.

They w ere se lec ted from patients attending a clinic forlimb-leng th discrepancy , and their only complaint w as thediscrepancy . N one had back pain.

There w as de finite asymmetry of the movements o fthe spine on lateral flex ion, particularly noticeable after

the limb-length discrepancy w as neutralized. Then, nearlyalw ays, a considerable reduc tion o f lateral f lex ion tow ardthe side o f the short limb w as ev ident. The m ethod ofm easuring lateral flex io n of the spine w as described andassessed by M oll et a! . , w ho found a w ide scatter o f mea-surements for each decade o f life , but there w as a highdeg ree of accuracy and repeatability o f measurements foreach patient no matter w hat his or her ag e.In the present s tudy , the te st w as perfo rm ed underonly one static conditio n. It is poss ible and perhaps prob-able that spinal movement w ould have become more sym-metrical if, during a period of months or years, treatm entin the fo rm of neutralization of the anisomelia had beenadm inistered to these patients . N ev erthe le ss , the asym-metry w as very marked under the conditio ns o f this s tudy .

In 1 964 Scheller noted that there w ere different typeso f sco lio sis assoc iated w ith anisomelia, sometimes invo lv -ing even the cerv ical spine . In our study the curves w erelumbar except for one that ex tended to the e levenththo rac ic ve rtebra.

A fter neutralization o f the limb-length inequality theCobb ang le w as reduced considerably , but it w as notalw ay s to tally correc ted. A n abnormality consisting o f ashift to the side of the sho rt limb frequently pers istedabov e the lumbar reg ion of the spine, but the pattern w asunpredic table and no re lationship to the degree o fanisom elia w as de tec ted. N early all patients also w ere le ftw ith some loss o f lateral f lex ion to the sho rt side . It is no tknown w hat m ight hav e happened to this shift if the pa-tients had been treated w ith leve ling o f the pe lv is for a pro-long ed period of time .

A x ial ro tation is difficult to measure radio graphicallyw ith accuracy , but de finite ro tatory de form ity w as seen innearly all patients be fo re the limb-length discrepancy w asneutralized. W ith neutralization there w as generally aconsiderable reduc tio n in the ax ial ro tatio n but in a numberof patients there w as som e residual ro tatio n.

The unpredic table changes that w e observed w hen w elev eled the pe lv is in our patients sugg est that it m ight beadvisable for an adult w ith anisomelia to w ear a co rrectiv edev ice in the shoe for several months prio r to surg ical cor-rec tion (that is , if an operation is indicated). A fter the trialinterval, the type o f study that w e have described might bedone to asse ss w hat the effec t o f a correc tion o f sacral tiltw ould be on the spinal balance , and v ice versa.

NO T E : T h e a u t h o r s w ou ld like to thank Pro fesso r R . A . D ickson and D r. P. S tamper fort he ir a dv i ce a n d M rs. J. M aliphant for her help w ith the study .

R e f e r e n c e s1. C O B B , J . R .: O u t lin e fo r t h e S tu d y o f S eolios is. In Instruc tional Course Lec tures, The American A cademy o f Orthopaedie S urg eons. V o l. 5 , pp.

2 61-275 . A nn A rbor, J. W . Edw ards, 19 48 .2. C O E T S I E R , M .; VER C AUTER EN , M .; a n d MO E R MA N , P .: A N ew R a d iog r a p h ic M et h od fo r M ea su r in g V e r t e b r a l R o t a t ion in Seoliosis. A et a O r t h o p .

B elg ica, 43 : 598-605 , 19 77 .3. D I C K S ON , R . A .; ST AM PE R , P E T ER ; SH AR P , A .-E .; a n d H AR K E R , P AUL : Sch ool Sc r een in g for Scolios is : C oh o r t S tu d y of C lin ic a l C ou r se . B r it ish Med.J . , 281 : 2 65-267 , 1 980 .

4. J AME S , J . I . P .: S co lios is. E d . 2 , p . 3 3 . E d in b u r g h , C h u r ch ill L iv in g st o n e, 19 76 .5. M O E , J . H .; W I N T E R , R. B .; B R AD F OR D , D . S .; a n d LON S T E I N , J . E .: Sco lio sis a n d O th er S p in a l D efo r m it ie s, p . 10 . P h ila d e lp h ia , W . B . Sa u n d er s,

1978 .6. MO L L , J . M . H .; L I YANAGE , S . P .; a n d WR I G H T , V .: A n O b j e ct iv e C lin ic a l M eth od t o M ea su r e L a t e r a l Sp in a l F lex io n . R h eum a t . a n d P h y s. M ed .,1 1 : 225-239 , 1972 .

7 . NA SH , C . L., J R . , and M O E , J . H .: A S t u d y of V er t eb r a l R o t a t ion . J . B on e a n d J o in t Su r g . , 51-A: 223 -22 9 , M arch 1969 .8. S C H E L L E R , M . L.: Uber de n Einfluss der B einve rkO .rz ung auf die W irbels#{ 228 } ule . The sis. U niv ersitat zu K#{ 246} ln,Co logne, West Germany, 196 4 .

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