unilateral limb lengthening associated with haematogenous ... · to increase in length of a long...

UNILATERAL LIMB LENGTHENING ASSOCIATED WITHHAEMATOGENOUS OSTEITIS IN CHILDHOOD

BY

WALLACE M. DENNISONFrom a Surgical Unit, Royal Hospitalfor Sick Children, Glasgow

(RECEIVED FOR PUBLICATION MAY 2, 1951)

Increase in girth of a long bone following pyogenicinflammation is well known, but there is little recentliterature describing increase in length followingprolonged bone infection. In a recent series of100 cases of acute haematogenous osteitis treatedwith penicillin the disease affected a long bone on84 occasions. Measurable increase in length of theaffected limb occurred in 20 cases. During the samefive-year period increase in length of the lower limbwas also noted in conditions other than pyogenicbone infection.The effects of alteration in circulation on bone

growth have interested many observers. In thesixteenth century Ambroise Pare noted that stasishyperaemia stimulated bone growth, and heemployed hyperaemia to stimulate callus formationin fractures. Three centuries later Thomas (1886)rediscovered the value of venous stasis in fractureswith retarded callus formation. Stanley (1849),Paget (1853) and Bergmann (1868) showed thatany long-continued inflammatory process would befollowed by increase in length and girth of the bones.Bier (1905) referred to the effects of stasis hyperaemiaon bone growth and his book furnishes an excellenthistorical review of this subject. In recent workson bone disease and fractures there is little referenceto increase in length of a long bone produced bycirculatory derangement.Although limb lengthening is most commonly a

sequel to haematogenous osteitis, increase in lengthof the lower limb was noted in the following condi-tions seen in one unit of the Royal Hospital for SickChildren, Glasgow, during the past five years:(1) 2 cm. lengthening after simple transverse fractureof the femur; (2) 3 cm. lengthening associated witha diffuse angiomatous condition of one leg (con-genital arteriovenous fistulae); (3) 2 cm. lengtheningafter recurrent haemarthrosis of one knee in achild suffering from haemophilia; (4) 2 5 cm.lengthening after severe lacerations of the thigh andcalf; (5) 2 5 cm. lengthening in a child sufferingfrom synovial tuberculosis of the hip; and (6) 3 cm.

lengthening associated with congenital neurofibro-matosis (biopsy revealed plexiform dilatation ofveins). In all these conditions there is a commonfactor of increased blood supply. Leriche andPolicard (1926) have suggested an indirect vasculareffect on bone growth by the sympathetic nervoussystem. We have found an increase in length of onelower limb ofat least 1 cm. following unilateral lumbarganglionectomy performed for various conditions.

Before the introduction of penicillin in thetreatment of osteitis gross limb lengthening wascommon and was due to the continuing hyperaemiacaused by the presence of an infected sequestrum.Although sequestrum formation was much lesscommon in the penicillin-treated cases, it stilloccurred (Dennison, 1948) and Figs. 1 and 2 showexamples of the resultant increase in length of theaffected limb. Where only one of two paired boneswas diseased, the increase in length affected bothbones equally (Figs. 3 and 4). The hyperaemiapresumably affects the soft tissues and increases theblood supply throughout the segment. Irregulargrowth occurred when there was damage to onepart of the epiphysis (Figs. 9 and 10). The increasein length varied from 1 to 3 cm. and the lengtheningusuaUly became obvious eight to 12 months afterthe onset of the disease. The patients were all under13 years of age at the time of onset of the boneinfection.

Sterile sequestra are usually absorbed (Bancroft,1921) but an infected sequestrum unless extrudedmust be removed surgically. In 25 successivesequestrectomies performed during the past fiveyears, coagulase positive staphylococci have beengrown from either the sequestrum or the surroundinggranulation tissue in 24 cases. Advantage of thisknowledge was taken in one case in the penicillin-treated series. Pathological fracture of the upperand lower ends of the femur complicating severebipolar osteitis was followed by 1 cm. shorteningof the affected leg (Fig. 5). Radiography revealeda cavity with sequestrum formation, and at operation

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FiG. I.-Case S.E. Osteitis of right femur. Photographs show 2-5 cm. increase in klgthof right leg with pelvic tilt, corrected by 2-5 cm. block under foot on sound side.

leg and pelvic tilt, corrected by 2 cm. block under foot on sound side. X-ray film showsincrease in length and girth of left femur.



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FIG. 3.-Case J.G. Osteitis of right tibia. Radiographof both tibiae on one film, 18 months after onset of acuteosteitis, showing sclerosis of right tibia and increase in'

length of both right tibia and fibula.

FIG. 4.-Case M. McH. Osteitis of ulna. Radiographfilm of both forearns, showing increase in girth of rightulna and increase in length of right ulna and radius, two

years after onset of acute osteitis.

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FiG. 5.-Case M.H. Photographs show shortening of left leg and slight pelvic tiltcorrected by I cm. block under klft foot. X-ray film shows coxa vara followingpathological fracture of the neck of the left femur, sclerosis of the shaft and cavitation

in lower quarter.

FIG. 6.-Case M.H. (eight months later). Legs of equal length in photographand x-ray film.

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FK;. 7 -Case J.P. Osteitisof right femur. Fouryears after onset. Photo-graphs show scoliosis andgenu valgum partiallycorrected by 2 cm. blockunder foot on normal side.X-ray film shows sclerosisand increase in kngth and

girth of right femur.

FK;. 8.-Case L. McI.Osteitis of right femur.Photographs show genuvalgum following over-growth of right femur.X-ray film shows sclerosis vand increase in girth and

length of right femur.

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LIMB LENGTHENING ASSOCIATED WITH HAEMATOGENOLUS OSTEITIS 59

on February 12, 1949, three small infected sequestrawere removed. A fourth sequestrum was deliberatelyleft in situ to promote bone growth. On October 4the remaining sequestrum was removed and Fig. 5(October 16) shows both legs of equal length.The growth stimulus over-activated by the

increased blood supply gradually passes off and inthe actively growing child a moderate increase inlength (up to 2 cm.) is rectified within five years.In a series of cases of osteitis treated before theintroduction of chemotherapy and followed up untiladult life (10-15 years later) an increase in lengthof 3 cm. noted between 1936 and 1940 was no longerpresent in 1950. Presumably growth ceases earlierin the overgrown limb.

It must be remembered that the growing childcan compensate for a long lower limb by suchpostural defects as scoliosis (Fig. 7) and genu valgum(Fig. 8). Constant watch must be kept on thepatient as such deformities develop insidiously overa period of years if suitable raising is not applied tothe footwear of the normal leg.

FjG. 9.--case B.m. Osteitis of left femur. Flexiondeformity following damage to lower femoral epiphysis.

FIG. 10-.Case K.M. Osteitis of right tibia (b) two weeksafter onset; (c) five weeks after onset; (a) seven monthsafter onset, overgrowth of medial tibial condyle causing

genu valgum.

In 100 cases of acute haematogenous osteitis thedisease affected a long bone on 84 occasions.Measurable increase in length of the affected limboccurred in 20 cases.Limb lengthening occurs in other conditions in

which there is an increased blood supply to the part.Examples of such conditions are mentioned.

Unless appropriate action is taken secondarypostural deformities may follow increase in lengthof one lower limb.

The cases were all studied in Mr. White's surgicalwards and I am grateful to him for his helpful advice andcriticism. I wish to thank Mr. J. L. A. Evatt, A.R.P.S.,medical photographer, Royal Hospital for Sick Children,Glasgow, for the photographs and reproductions ofx-ray films.

REFERENCESBancroft, F. W. (1921). Ann. Surg., 73, 681.Bergmann, E. (1868). St Peters. med. Z., 14, 65.Bier, K. G. A. (1905). Hyperemia as a Therapeutic

Agent.' (Trans.), edited by G. M. Blech, Chicago.Dennison, W. M. (1948). J. Bone Jt Surg., 30B, 1 10.Leriche, R. and Policard, A. (1926). Surg. Gvnec.

Obstet., 43, 308.Paget,J. (1853). 'Lectureson Surgical Pathology.' London.Pare, A. 'Oeuvres completes d'Ambroise Pare,'

1840-41. Paris.Stanley, E. (1849). ' A Treatise on Diseases of the

Bones.' London.Thomas, H. 0. (1886). 'Contributions to Surgery and

Medicine, Part 6: The Principles of the Treatmentof Fractures and Dislocations.' London.



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unilateral limb lengthening associated with haematogenous ... · to increase in length of a long...

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