EDUCATIONAL UPDATE

Limb shortening for the management of leg length discrepancy

CRISTIANO COPPOLA, NICOLA MAFFULLI
Department of Orthopaedic Surgery, University of Aberdeen Medical School, Aberdeen, Scotland

Limb shortening is an option to manage leg length discrepancy (LLD). Before skeletal maturity, a LLD between 2 and 5 cm can be corrected by epiphyseodesis (open or closed) or stapling. All these procedures require exact timing of surgery. In skeletally mature patients, shortening of the femur is considered safer than tibial shortening. Subtrochanteric and supracondylar osteotomies fixed with a blade-plate can be used to correct associated deformity. Mid-shaft shortening can be performed by a closed or open method. Closed shortening has been widely used, but frequent malrotation, loss of function and acute respiratory distress syndrome following reaming have been reported. Therefore, the use of a nail locked proximally and distally, and caution in reaming the canal, are strongly recommended. For LLDs greater than 10 cm, lengthening should be considered, although a one-stage two-limb procedure can be used, whereby shortening is performed on the longer limb, and the excised bone segment is implanted in the contralateral limb to be lengthened. However, when shortening procedures are performed in skeletally immature patients, they require precise timing, and indications and technical details must be strictly observed.

Keywords: leg length discrepancy, limb shortening

J.R.Coll.Surg.Edinb., 44, Feb 1999, 46-54

INTRODUCTION

Distraction osteogenesis has been used for the management of lower limb length discrepancy (LLD).1-5 Although reliable, distraction lengthening can be a long and complicated procedure. Many conditions are responsible for LLD at different ages6 (see Table 1), and limb shortening is one of the procedures used for correction of LLD or overgrowth in both adults and children. Rizzoli, in Bologna, Italy, probably first reported the correction of LLD by shortening in 1847, excising a segment of the femur from the normal limb.7 This review examines the indications and results of various shortening procedures, and tries to formulate evidence-based guidelines for the choice of the appropriate shortening procedure.

Table 1: Causes of lower limb length inequality

  1. Congenital anomalies
  2. Developmental and tumoural conditions of the skeleton and soft-tissue malformations.
  3. . Infections and inflammatory conditions affecting the growth plate or increasing blood supply to the epiphyseal and metaphyseal regions.
  4. Trauma
  5. Neuromuscular conditions
  6. Others (slipped upper femoral epiphysis; Legg-Perthes disease; prolonged immobilization by weight-relieving orthoses; radiation therapy and arrest of physeal growth)

Adapted from: Tachdjian MO. Pediatric Orthopedics. Philadelphia, USA: WB Saunders Company, 1990; vol. 4:2850-3012.

INDICATIONS

If it has been decided to surgically manage a patient with LLD, it becomes necessary to consider the value of shortening of the healthy limb, versus a long, time consuming procedure, such as lengthening of the affected limb (see Table 2).8 Shortening may be preferable to lengthening because it is quicker and simpler, produces less severe complications, allows faster mobilisation, shorter hospitalisation, and lower costs.

Limb lengthening has the advantages of maintaining height and body proportions, and of performing surgery on the affected side.1 However, it can lead to joint contractures, muscle weakness, angulation, malunion and non-union, infections around pins, interference with the blood supply, prolonged hospitalisation, multiple admissions and operations.2,9,10

Shortening to correct LLD can be performed in both skeletally mature and immature patients. Before skeletal maturity, some procedures are highly effective for correction of discrepancies between 2 and 4 cm 8,11,13 and up to 5 cm.6, 14-17

For greater discrepancies in the skeletally immature patients, lengthening should be considered.6,8,13 In skeletally mature patients, shortening may be indicated in more significant LLD (from 4.5 to 16 cm in the femur, 18,11,13,18-23 and from 3 to 8 cm in the tibia.8,12,13,15,23)

Some patients can compensate a LLD of 3 cm, while others respond with an abnormal body posture, non-physiologic gait patterns, and pain. Generally, a leg length discrepancy of 1-2 cm is well tolerated.24 However, some patients may feel unbalanced, and may present with an unacceptable limp and backache25, and/or with no symptomatic improvement after using a shoe-raise for several months. In such cases, shortening is an option.12,13,26-28

A compensatory lumbar scoliosis may result after femoral fractures.28 After equalisation with a corrective shoe-raise, the overall curve and the axial rotation can be corrected completely,29 although some studies have shown that structural changes and back pain may develop.30,32 On the other hand, Rossvoll et al33 reported improvement of back pain in 22 patients with an average LLD of 3.2 cm and low back pain.

Patients with avascular necrosis after treatment for develop-mental hip dysplasia34, patients with Poland's syndrome35, Klippel-Trenaunay-Weber and Proteus syndromes36, discrepancies of 3 cm or less, coupled with other deformities, may require surgery.

Table 2: Comparison of advantages and disadvantages of surgical shortening or lengthening

PROCEDURE ADVANTAGES DISADVANTAGES
LEG LENGTHENING
  • Surgery on the affected limb
  • Correction of accompanying deformities
  • Preservation of body length
  • Normalisation of body proportions
  • Significant gain of length 
  • Consolidation problems
  • Increasing problems with advancing age
  • Operation technically difficult
  • Possible multiple surgery
  • Soft tissue tension
LEG SHORTENING
  • Short hospitalisation
  • No bony consolidation problems
  • Operation technically easy
  • No restriction of joint motion
  • Operation of the uninvolved limb
  • Operation on both legs necessary if concomitant deformities have to be corrected
  • Compensation of deformity
  • Diminution of total height
  • Possible interference with body proportions
  • Limited correction of up to 10 cm
  • Lengthening of the shortened limb often necessary

Adapted from: Wagner H. Surgical lengthening or shortening of femur and tibia. Technique and indications. Progress in Orthopaedic Surgery 1977; 1: 71-94.

SHORTENING OF FEMUR VERSUS TIBIA

In general, femoral shortening is indicated in adolescents with LLD near skeletal maturity or in young adults of normal or tall stature.5 Although no age limits are reported, femoral shortening is rarely performed in patients older than 45 years.13 In the femur, more bone can be removed than in the tibia. Femoral shortening seems safer than tibial shortening, which is often associated with wound closure problems, high malunion rate, and skin necrosis.13 Broughton et al 37,however, described satisfactory results from tibial shortening in 12 patients with LLD between 2 and 7.5 cm. Considerable shortening of the tibia can lead to abnormal proportions of body segments13 and, often, patients who undergo tibial shortening complain of a localised increase in the bulk of the leg.

PREOPERATIVE ASSESSMENT

Clinical examination

Both limbs should be measured. Absolute length is the distance between the most proximal part of the femoral head and the point of contact of the foot with the ground. Anatomical length is the distance between the proximal end of the grater trochanter and the distal end of the lateral malleolus. Apparent length is the distance between the umbelicus and the end of the medial malleolus. Clinical length is the distance between the anterior superior iliac spine and the distal end of the lateral malleolus.38 Careful examination is also needed to exclude any structural scoliosis.

Radiograph

Clinical measurements must be completed with an antero-posterior radiograph of the lumbar spine, including the lumbo-sacral junction, with a block under the foot of the shorter leg to simulate the effect of the proposed surgical correction. An antero-posterior standing radiograph of both lower limbs should be obtained, again with a block under the foot. Computerised tomography (CT) scanning is considered the most accurate method to measure bone length of the femur and tibia.39,40 Magnetic resonance imaging (MRI) and ultrasound scanning have also been used.41,42

Prediction of growth

In skeletally immature patients with LLD, accurate prediction of growth is essential for pre-operative planning: surgery may be performed too late, and the discrepancy may not be sufficiently corrected, or too early, with overcorrection. Most surgeons err on the side of caution. The factors to consider for appropriate surgical timing include the following: (a) the skeletal age; (b) the projected time to skeletal maturity; (c) the amount of growth inhibition of the shortened limb; (d) the anticipated LLD at skeletal maturity.

One of the wider used methods for skeletal age estimation is that of Greulich and Pyle43, which is more reliable than the Tanner and Whitehouse method44, although the precision of the resulting estimated ages has recently been widely criticised.45-47 Also, various conditions may have an altered pattern of ossification that may influence skeletal age estimation.45

Other methods to estimate residual growth have been proposed in the last fifty years. Green and Anderson48-52 proposed a method of standard deviation, in which skeletal and chronological ages, parental height, relative maturity and growth of the individual were considered to predict the amount of future growth. Menelaus53 with Westh54 described a simpler method based on chronological rather than skeletal age. Moseley55 presented the 'straight-line graph'. The method automatically took into consideration the child's growth centile and the degree of growth inhibition in the shorter leg, and was also used to predict the effects of corrective surgical procedures and to plan the timing of surgery. Often, these methods are used in combination56, although the Moseley graph is more accurate.14,57

SURGICAL PROCEDURES AND RESULTS

LLD can be corrected by limb shortening using any one of the following techniques: (a) permanent arrest of the growth of the longer limb by epiphyseodesis; (b) retardation of growth of the longer limb by epiphyseal stapling; (c) open or closed femoral and tibial osteotomies fixed by plate or intramedullary nailing. Some methods, including the 'tongue in groove' osteotomy method of femoral shortening7,have only historical importance.

Epiphyseodesis

Distal femoral and proximal tibial epiphyseodesis has been the most commonly used procedure for equalisation of LLD between 2 and 5 cm at maturity.58 Some authors used epiphyseodesis to correct excessive tall stature in boys59 (see Table 3). Open epiphyseodesis includes curettage of the physis to permit ingrowth of epiphyseal and metaphyseal bone, destruction of the perichondrial ring, and usually bone grafting across the plate by reorientation of the bone window removed to gain access to the physis.60 Percutaneous epiphyseodesis61,62 has similar indications. A guide pin is inserted through a small incision under image intensifier control, identifying the medial and lateral borders of the distal femur or proximal tibia. A very small bone block is removed and, with a small curette, the physis is destroyed. At the end of the procedure, contrast medium can be instilled at the site of the curetted growth plate, and a plain radiograph taken to ensure that the physis is completely destroyed.

An additional indication of percutaneous epiphyseodesis is partial growth plate ablation to correct angular deformity.16 Percutaneous epiphyseodesis is reliable, and shows low morbidity, a high rate of success, and minimal invasiveness, both in experimental and clinical studies.63 Canale and Christian64 performed percutaneous epiphyseodesis using a high-speed dental burr. Ogilvie and King65 obtained good results using a low speed, high-torque drill, and Atar et al66,67 used a 4.5 mm drill. Liotta et al68 and Horton and Olney69 produced small scars, little post-operative knee stiffness, and a very short hospital stay. Macnicol and Pattinson56 and Macnicol and Farley70 used a cannulated tube saw to approach the growth plate from one side only. The device also produced an opening large enough to permit further curettage of the physis without resorting to powered instruments. This method was used in 10 children aged 10-14 years.71 Discrepancies of 2-5 cm were reliably reduced to < 1 cm. The same group reported the results of the technique in 35 patients for predicted LLD of 2 to 4.5 cm. The LLD was reduced to 0.7 ± 0.6 mm.72

Table 3 : Epiphyseodesis: analysis of results

Authors Year Methods Number of Patients Average age (years) Average LLD (cm) Average final LLD (cm) Complications
Straub et al 1945 OE 89 13 2.5
50.6%>2		 49.4%,2 8 cases; deformity requiring operative correction
Stamp and Lanwsche 1960 OE 102 Unknown Not specified Not specified 4 cases of genu valgum (one with patellar dislocation), one case of progressive shortening
Mayhall 1978 OE 35 14 4 2 8 cases, including overcorrection, infections, knee joint contracture, genus valgus/ varus, myositis ossificans
Westh and Menelaus 1981 OE 94 12 4 <2 10 cases, including infections, bony prominence, valgus/ varus deformity, overcorrection
Blair et al 1982 OE 67 12 4.4 1.9 66% of undercorrection due to inappropriate time of surgery
Bowen and Johnson 1984 PE 12 12 Not reported Not reported (Phemister's indications cited) None
Ogilvie and King 1990 PE 7 13 4.27 2.55 None
Atar et al 1990 & 1991 PE 9 13.5 3.5 Not reported None
Canale and Christian 1990 PE 22 - 4.1 3.2 One case of persistent sciatic nerve palsy
Timperlake et al 1991 PE 50 13 3.2 1.5 2 cases, including post- op haematoma and exostosis
Porat et al 1991 PE+OE 20 12 4 0.6 3 cases, including drop foot and knee effusion
Dewaele and Fabry 1992 OE 83 12.5 3.37 1.69 8 cases, including overcorrection, asymmetrical closure, infection, absence of closure of the epiphyseal plate
Lampe et al 1992 OE 30 11.4 5.2 1.4 11 cases, including operation failure, insufficient preoperative measure ments, delay in skeletal maturation, premature fusion of damaged growth plate
Macnicol et al 1993 PE 10 12 3.5 <1 None
Gabriel et al 1994 PE 29 12 3.75 <1 5 cases, including transient knee effusion, tibial stress fracture, superficial wound dehiscence and infection
Horton et al 1996 PE 26 12.7 Not reported Not reported One knee effusion, one persistent knee stiffness
Little et al 1996 PE(=61)
OE(=49)		 110 only
71 included in the study		 11.6 (F)
13.5 (M)		 3.12 1.05 19 patients had discrepancy > 2.0 cm, and 24 patients had discrepancy >1.5 cm at maturity
Macnicol et al 1997 PE 35 13.5 3.3 0.7 One overgrowth of fibula, two hypertrophic scars
Plaschaert et al 1997 OE 6 14.5 None (excessive height) None (height reduction of 9.3 cm achieved) One superficial wound infection, one post- operative haematoma, two hypoesthesiae of the saphenous nerve, one exostosis, three knee effusions

OE: open epiphyseodesis, PE: percutaneous epiphyseodesis, F: female, M: male

Epiphyseal stapling

Epiphyseal stapling produces a temporary arrest of longitudinal growth by staples.73 When the LLD is corrected, the staples are removed, and growth can resume.49,74-80 Staples must be placed perpendicular to the growth plate, the periosteum and epiphyseal vessels should be left intact to avoid permanent growth inhibition, and the staples position must be verified radiographically.81 Roentgen-stereophotogrammetry can be used to analyse pre- and post-operative growth pattern after stapling.75 Indications for stapling are moderate LLD, usually in the femur, with bone age between 8 and 11 in girls and 8 and 13 in boys. Stapling is particularly effective if valgus and/or recurvatum deformity is combined with LLD81, with reliable correction of LLD.82

Some authors have considered physeal stapling useful only when it is difficult to predict the amount of correction to be obtained by epiphyseodesis, as in multiple hereditary exostosis or other skeletal dysplasias with marked irregularity of skeletal maturation.6

Osteotomy

Resection of a segment of femur or tibia for equalisation of limb lengths should be performed only after skeletal maturity is reached (see Table 4). Generally, femoral shortening is preferred to tibial shortening, as larger resections are possible. Femoral shortening can be performed by open or closed methods at the subtrochanteric, mid-shaft, and supracondylar levels26, and the osteotomy fixed by plating or intramedullary nailing.

Table 4: Advantages and disadvantages of different osteotomy procedures

OSTEOTOMY LEVEL PROCEDURE (reference) FIXATION ADVANTAGES DISADVANTAGES
SUBTROCHANTERIC Open (6,26) Blade plate Ease of performance; appropriate  to correct associated deformities  (coxa vara or valga) Infections, bleeding, long scar, removal of plate (if required) can be technically difficult
MID SHAFT Open transverse osteotomy (39, 93) Intramedullary nailing Easy removal of the bone fragment Infections, quadriceps weakness, loss of function, delayed union or nonunion, instability, telescoping or rotatory deformity, intramedullary nail backout
    Intramedullary locked  nailing Control of rotation Infections, delayed union, nonunion, long procedure, multiple scar
  Open step- cut osteotomy (17, 26, 41) Intramedullary nail with screws or a short plate with unicortical screws    
  Open one stage (17) Intramedullary nailing Correction of severe femoral shortening Infections, delayed union, nonunion, knee shortening flexion contractures, sciatic nerve palsy
  Closed ( 5, 23, 48, 82, 100 ) Reamed intramedullary nailing Low infection rate; cosmetically acceptable scar Technically difficult, increased bulk in the  leg, loss of function, acute distress syndrome, delayed union, nonunion, rotatory malalignment
    Reamed locked intramedullary nailing More stable internal fixation Same disadvantages as the above technique, intramedullary nailing but minor risk of rotatory malalignment
SUPRACONDYLAR Open (64) Plate Correction of associated genu  valgum or varum or recurvatum deformities Technically difficult, close to the knee - joint stiffness, infections
  Open (7) None (tongue- in- groove')    

Subtrochanteric osteotomies fixed with a blade-plate are appropriate in LLD and coxa valga or vara, possibly with excessive femoral anteversion.8,83 Szepesi et al84 reported excellent results in 14 such patients, correcting an average LLD of 3 cm. Kenwright13 described an alternative fixation method by intramedullary nailing locked proximally or at both ends in cases of instability or of excision of a bone segment longer than 4 cm.

When there is no angulation deformity26,85,86 a simple transverse osteotomy at the mid-shaft femoral level, with resection of a segment of bone and intramedullary nailing, or a step-cut osteotomy with resection of bone from both fragments and internal fixation with locked intramedullary nailing87 or a short plate26, are most commonly used. Bianco26 reported 11 patients (average pre-operative LLD 4.5 cm) who underwent fixation with an intramedullary rod. Post-operative LLD averaged 8 mm. Johansson and Barrington47 reported 14 femoral shortenings (average LLD 5.6 cm) using a step-cut osteotomy and Kuntscher nail fixation, correcting the LLD to between 0 (6 patients) and 1.3 cm (7 patients).

The closed procedure relies on the use of an intramedullary saw20,28,88-91 after reaming the femoral canal. The two osteotomies are completed by osteoclasis. A special device is inserted, and the segment of bone is split along its longitudinal axis. The split segment is pushed out of the way, and the bone ends brought together. An intramedullary nail is inserted and locked proximally and distally.92

Winquist91 reported 154 patients undergoing femoral shortening for LLD from 2 to 12 cm: corrections ranged from 2 to 7 cm. Blair et al20 performed closed femoral shortening in 20 skeletally mature patients (average LLD 3.8 cm), obtaining a final LLD of < 1 cm. Eyres et al88 reported 15 patients with closed osteotomy and intramedullary nailing to correct LLD, rotational and axial deformities, and malunions of the femur. All deformities were corrected, and 5 patients with an average LLD of 5 cm achieved a final LLD < 1 cm. Sasso et al90 reported 18 patients with an average LLD of 5 cm reduced to 0.6 cm.

Supracondylar metaphyseal femoral shortening is indicated in LLD with genu varum, genu valgum, or genu recurvatum requiring correction.93 A trapezoid segment of bone is resected, and the osteotomy is fixed by plate. The procedure is technically more difficult than shortening at the mid-shaft or subtrochanteric levels, and it is difficult to obtain accurate reduction of the osteotomy and secure internal fixation. The 'tongue-in-groove' method can be used if internal fixation is not indicated, or not available.7 In 20 patients, Stamp and Lansche7 reported one fracture at the osteotomy site, one genu valgum, and one genu recurvatum.

D'Aubigne and Dubousset89 performed a one-stage bilateral femoral equalisation procedure. The long femur is shortened and the bone graft thus obtained is used to lengthen the shorter femur. They recommended the method to correct an LLD of 10 cm or more in older children and young adults. In 13 patients with an average pre-operative LLD of 14.6 cm, five had a correction of 9 cm, one a correction of 8 cm, two a correction of 6 cm, and one a correction of 5 cm.

COMPLICATIONS

The outcome of open or percutaneous epiphyseodesis depends mainly on the timing of surgery. Despite the good results, there is always between 10%94 and 30%47,57 of unsatisfactory results, mainly due to the inaccurate prediction of the correction achievable and the timing of surgery.14,15,47,95 Inaccurate timing is due to inappropriate prediction52, misinterpretation of the developmental pattern of the LLD96, and inaccurate estimation of skeletal age.45,95 Over- and under-correction, partial growth arrest and angular deformity, neurovascular dysfunction, exostosis formation, post-operative infection and restricted joint motion have often been described.17,46,47,50,54,56,57,94,97-100

Epiphyseal stapling inhibits growth less promptly than epiphyseodesis.51 The periosteum and the physis should not be disturbed placing and removing the staples, and accurate timing is necessary. Complications are asymmetrical growth with genu valgum, varum or recurvatum, secondary knee laxity, infections, extrusion of staples, failure to control growth, loss of correction after removal of staples, and peroneal nerve palsy.50,74,75,78,79,101

In skeletally mature patients, tibial shortening is not widely practised. Broughton et al37 reported good results using a step-cut method; some patients developed neurovascular disorders or loss of function. Tibial fixation can be troublesome, and intramedullary proximally and distally locked nailing has been advocated19, but complications include infection, calf muscle weakness, axial deviation, malunion or non-union, and skin necrosis.13

After femoral shortening, quadricipital weakness with extension lag of the knee and genu recurvatum due to hamstring weakness is common. Following shortening of the femur, the muscle cross-section area of both type 1 and type 2 fibres in the vastus intermedius in rats decreases, and muscle fibres atrophy.102 Nordslatten et al21 reported no quadricipital weakening following subtrochanteric shortening, but patients undergoing mid-shaft osteotomy experienced significant knee extension weakness, probably due to damage to the origins of the vasti muscles.

Subtrochanteric osteotomy with blade-plate fixation is reliably stable, but requires an extensive lateral incision. Also, removal of the blade-plate, when required, is technically demanding. Kenwright and Albinana92 used an intramedullary nail locked proximally in 46 leg shortening operations. Eleven patients reported loss of function, and 4 developed non-union.

Intramedullary nailing for diaphyseal shortening of the femur can be unstable, and telescoping or rotatory deformity are frequent. Thompson et al86, after 51 mid-shaft femoral osteotomies fixed by locked intramedullary nails, reported 18 complications, including subtrochanteric pain, infections, loss of full active extension, genu recurvatum, sciatic nerve palsy, non-union, angulation after breaking of screws, broken and bent nail.

Although a step-cut osteotomy can be made in the femur27,103 or a short plate can be added to supplement the intramedullary fixation26, even these modifications may be associated with overcorrection, delayed union, nonunion, or intramedullary nail back-out. Closed shortening of the femur can lead to major complications such as malrotation and loss of function. In 40 patients undergoing closed femoral osteotomy and intramedullary nailing without locking, Winquist et al28 reported one delayed union requiring renailing, and two symptomatic external rotation deformities requiring correction. Rotatory malalignment and loss of function have also been described in other series20,90,92 and proximal and distal locking is recommended to prevent these complications.90 Acute respiratory distress syndrome can occur during closed femoral shortening following reaming of the femur. Matson and Johnson104 demonstrated a 4% incidence of fat embolism after closed femoral shortening, and Namba et al105 reported two patients with acute respiratory distress in 43 operations. Sasso et al90 recommended that the canal be entered slowly and gently through an enlarged portal at the piriformis fossa to allow the intramedullary contents to be expressed back through the entry hole.

Other problems encountered are the technical difficulties to completely separate the intercalated segment from both the upper and lower main bone fragments, and in splitting it along its longitudinal axis. If this is not done, unacceptable increased bulk of the thigh may result.20,92,106 D'Aubigne and Dubousset87, reporting the results of a one-stage bilateral femoral equalisation, found a 6% rate (1 of 16 cases) of hip and knee flexion contracture and transient limb ischemia, and a 19% (3 of 16 cases) incidence of delayed union and transient sciatic nerve palsy.

CONCLUSIONS

Limb shortening, although requiring exact timing of surgery, offers a valid choice for the treatment of LLD. Before skeletal maturity, a LLD between 2 and 5 cm can be corrected by epiphyseodesis or stapling. Each technique leads to effective physeal closure, although the Phemister and the staple method produce more rapid deceleration of growth.107 In contrast, the percutaneous technique requires ablation of a larger portion of the physis. The irreversible destruction of a growth plate should never be undertaken lightly.54 For an LLD greater than 5 cm in skeletally immature patients, leg lengthening should be considered. In skeletally mature patients, femoral shortening is considered safer than shortening of tibia. Corrections between 2 and 7.5 cm in the femur and not greater than 3 cm in tibia are recommended to avoid significant complications. Several different osteotomies have been described at different levels. Subtrochanteric and supra-condylar osteotomies fixed with a blade-plate can be used to correct associated deformity. Mid-shaft shortening can be performed by closed or open method. The osteotomy can be fixed with a locked intramedullary nail, or with screws. In the latter case, a short plate can be added. Closed shortening has been widely used, but frequent malrotation, loss of function and acute respiratory distress syndrome following reaming have been reported. Therefore, the use of a nail locked both proximally and distally, and caution in reaming the canal, are strongly recommended. The open procedure should be considered to overcome the technical difficulties encountered with the closed method. It allows excision of the mid-diaphy-seal segment, preventing unacceptable increased bulk in the leg, and allows the addition of a plate to control possible malrotation.

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Copyright date:11th December 1998

Correspondence: Nicola Maffulli, Department of Orthopaedic Surgery, University of Aberdeen Medical School, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, Scotland. E-mail: n.maffulli@abdn.ac.uk

©1998 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb., 44, February,46-54