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Home , Arthropathy, Protrusio acetabuli, Valgus deformity

Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from Ann. rheum. Dis. (1969), 28, 359

LONG LEG * BY A. ST. J. DIXON AND S. CAMPBELL-SMITH Bath

There are now abundant examples of the way in Thus Coste and Forestier (1935) showed that hemi- which mechanical factors concerned with the use of plegia protected against the development of Heber- a limb influence the pattern and severity of subse- den's nodes and Glyn, Sutherland, Walker, and quent irrespective of diagnosis, both in Young (1966) that the of the paralysed limb inflammatory and non-inflammatory arth- in poliomyelitis had less tendency to arthrosis than rosis. For example, Jacqueline (1953) noted that, the non-paralysed joints. Similarly over-use of a in hemiplegic patients who subsequently developed joint with arthrosis increases the size of osteophytic , the paralysed side did not outgrowths. develop the clinical or radiological changes of This paper describes a common mechanical altera- rheumatoid arthritis, although biopsy (Thompson tion in the use of the which predisposes this and Bywaters, 1963) showed the synovium to be joint to more severe disease. This disordered gait affected. Similarly, disuse of a limb because of a occurs when a patient walks for a number of years copyright. lower motor neurone lesion such as poliomyelitis with an uncorrected inequality of leg length and will also protect against the subsequent development results in selective damage to the knee of the longer of rheumatoid arthritis (Secondo, Barboso, and leg. We have observed this whether the inequality Mellini, 1967). Kamermann (1966) showed that of leg length is apparent (due to ) disuse due to previous trauma will have the same or real (due to a true reduction in leg length) and effect. Courtright and Kuzell (1965) confirmed this whether it is due to damage to one hip from previous sparing effect of disuse in another patient and also , arthritis, congenital dysplasia, or trauma. in experimental adjuvant arthritis in rats. Con- Whatever the predisposing cause, the knee in the http://ard.bmj.com/ versely, increased use of a joint increases the fre- seemingly longer leg is then used abnormally. This quency and severity of arthritis. Thus, by using brings about more severe arthritis of the knee if the careful grading systems, Rotes Querol and patient is affected by rheumatoid arthritis, or more Roig-Escofet (1968) showed that there is usually precocious arthrosis of the knee if the patient is a more severe arthritis in the joints of the right than affected by osteoarthrosis. We refer to this as of the left hand. Van Dam (1964) and Soila (1963) "long leg arthropathy".

published similar findings with regard to radiological on October 2, 2021 by guest. Protected erosions of articular in rheumatoid arthritis. Case Reports Castillo, El Sallab, and Scott (1965) noted that Brief case histories illustrate the association: manual workers developed larger, more "cystic" (1) A 45-year-old woman developed of the erosions compared with non-manual workers left hip when she was 14 years old. This healed, but she affected by rheumatoid arthritis. We have observed thereafter walked without correction of the short left that, when patients develop ulnar deviation of the leg. At the age of 40 she noted a painful right knee. Fig. 1 (overleaf) shows the problem. There is about 5 fingers, it more frequently affects the right hand cm. of difference in leg length. The right knee shows before the left. Lindsay (1913) found involvement destruction of the lateral tibial compartment characteris- of the small joints of the hand to be more frequent on tic of long leg arthropathy. Clinically the knee was the right than on the left side in . slightly swollen and laterally hypermobile and showed In arthrosis similar observations have been made. some valgus and flexion deformity. Clinical and cinematographic studies have shown * Paper presented at a meeting of the Heberden Society on May 17 1968. that such patients walk with the "longer" leg flexed 359 360 ANNALS OF THE RHEUMATIC Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from

Fig. I .-Case 1, a woman aged 45. Tuberculosis of left hip at age 14. Subsequently walked with uqcorrected inequality of leg length.

Note changes in knee of longer leg. copyright.

and externally rotated at the hip and flexed at the (4) A 62-year-old woman with congenital dislocation of knee. During walking a strain is thrown on the the , developed generalized osteoarthrosis at the age http://ard.bmj.com/ knee so that it tries to bend into a valgus position. of 40 and shortening of the left hip at the age of 52 years. This repeated valgus strain may be the cause of the She now complains of more pain in the right (contra- damage we are describing. lateral) knee which has become subject to repeated effusions. This knee already shows increased lateral Four further patients show illustrative cases of mobility compared with the left. Fig. 4 (overleaf) con- varied aetiology. trasts the radiological appearance of the lateral tibio- femoral compartments of the two .

(2) A 69-year-old woman has bilateral coxarthrosis. A (5) A 67-year-old woman had osteoarthrosis of the left on October 2, 2021 by guest. Protected Smith-Peterson cup had been inserted on hip with an abduction deformity causing an apparent the left without correction of 4-5 cm. inequality of leg left leg lengthening of 4-5 cm. In this instance it was length. She has arthrosis in both knees, but the left the ipsilateral knee of the longer left leg which became knee does not trouble her while the right knee is painful painful and swollen and showed the radiological changes and shows more severe changes in the lateral compart- of osteoarthrosis. ment (Fig. 2, opposite). Merely to select certain patterns of joint disease (3) A 60-year-old woman gave a 10-year history of does not prove their significance. Therefore two rheumatoid arthritis with symmetrical involvement of further studies have been done to discover whether the knees until there was destruction of the right hip the association is true or due to selection. with and shortening of the right leg if there were no association of by 4 cm. This has been associated with the subsequent We have argued development of valgus instability and increased radiolo- knee arthropathy with the longer leg, patients who gical change in the left knee, which is now much more have primary shortening of one leg and who sub- painful than the right (Fig. 3, overleaf). sequently developed knee pain should do so with Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from LONG LEG ARTHROPATHY 361 copyright.

Fig. 2.-Case 2, a woman aged 69. Bilateral coxarthrosis. Left Smith Peterson cup arthroplasty without correction of . Arthrosis is present in both knees, but only the right is painful and swollen.

equal frequency in either knee. This proposition knees and had minor bilateral patello-femoral osteo- http://ard.bmj.com/ was tested in two separate surveys. arthrosis. Eight complained of pain in the knee of the shorter leg, so casting doubt on the validity of I. The first survey was done at the Winford our thesis. However, on examination, these knees Orthopaedic Hospital. 224 case histories of patients were all clinically normal and the pain was anterior known to haveunilateral hip disease in childhood and thigh pain referred from the damaged hip. One now over the age of 20 years were found in the of these eight patients had had two episodes of were hospital records and nineteen other patients locking in the ipsilateral knee. Nine of the eighteen on October 2, 2021 by guest. Protected seen in an appliance clinic attending for raised shoes. patients complained of pain in the contralateral knee From amongst these, by means of a questionnaire, and only three of these knees were clinically normal, we found 33 patients who fulfilled the following six showing painful with or without criteria: instability and three of these six knees showed radio- logical damage. In two of these this was confined (i) They had real or apparent leg inequality of leg length to the lateral tibio-femoral compartment. None of 2 5 cm. or more. of these patients had rheumatoid arthritis. (ii) They had subsequently walked with this uncorrected To summarize this first survey, in patients who had inequality of leg length for at least a year. shortening of 2 5 cm. of leg length or more and who (iii) They had subsequently developed symptoms (pain, subsequently developed pain in the knees, objective swelling, stiffness) in the knees. changes were almost always confined to the knee of the longer leg. Of these 33, eighteen accepted re-examination and fifteen refused or lived too far away. Of the eigh- II. The next survey was a 6-month period-of- teen re-examined, one complained of pain in both time study of all consecutive in-patients and out- Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from 362 ANNALS OF THE RHEUMATIC DISEASES copyright.

Fig. 3.-Case 3, a woman aged 60. Rheumatoid arthritis with symmetrical knee involvement until development of destructive shortening of right hip. Subsequently the left knee was more severely affected.

patients at the Royal National Hospital for Rheu- http://ard.bmj.com/ matic Diseases, Bath, and all patients of certain orthopaedic and geriatric wards in neighbouring hospitals. Altogether 1,431 patients were screened and, of these, 37 were found to have:

(i) Real or apparent shortening of one leg of 2 5 cm.

or more on October 2, 2021 by guest. Protected (ii) A subsequent history of walking on such legs for at least a year (iii) A clear history of no previous knee symptoms. In this survey, patients had to be excluded who suffered from both hip and knee disease and in whom it was impossible to discover retrospectively (e.g. from hospital records)whetherknees or hips had been affected first. Both arthritis and arthrosis were represented in this second survey. Of the 37 who answered the criteria, no less than in 24 was the contralateral knee the "worst" knee. In Fig. 4.-Case 4, a woman aged 62. Congenital dislocation of hips, with shortening of the left hip since age 52. Recurrent painful only one was there complaint of more pain in the effusions subsequently developed in the right knee. X ray contrasts ipsilateral knee, and in twelve the knees were either ateral tibio-femoral compartments of the knees, showing more advanced changes on the right. unaffected or equally affected. LONG LEG ARTHROPATHY 363 Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from The sequence of events clinically would seem to In several patients there has been reduction in pain be as follows: First, there is increased lateral move- in the knee after correction of the inequality of leg ment and limitation of normal movement; secondly, length and instruction in a proper gait. there is destruction of the lateral tibio-femoral In conclusion, we believe that there are a number of compartment of the knee with valgus deformity other recurring patterns of joint involvement in leading to crushing of the lateral tibial table. Pain rheumatoid arthritis and in osteoarthrosis, which may supervene at any stage. Secondary osteo- may well have a mechanical explanation due to arthrosis of the rest of the joint may develop later. disorders of gait or posture. These patterns ofjoint involvement are of obvious importance in the A sixth case history exemplifies the possible understanding of our treatment of these conditions clinical importance of these observations. and of the prevention of deterioration. (6) A 65-year-old woman with rheumatoid arthritis and destructive change in the right hip was very successfully Summary treated by arthroplasty (Fig. 5). Inequality of leg length "Long leg arthropathy" refers to a pattern of was not corrected after the operation and she subsequently joint damage seen in patients who walk for some walked freely but then developed a painful effusion of time with uncorrected of The the left knee. For this she was submitted to synovectomy inequality leg length. of the knee, which did badly, pain and swelling soon knee of the "longer" leg is liable to earlier and more recurring. We believe that the surgeon's attention was severe damage. This is exemplified by cases of drawn away from the underlying problem, namely in- varied aetiology, including arthritis and arthrosis. equality of leg length rather than active rheumatoid It is supported by two large-scale surveys of patients arthritis of the left knee. attending and orthopaedic hospitals.

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Fig. 5.-Case 6, a woman aged 65. Rheumatoid arthritis necessitating arthroplasty of the right hip with 4 cm. shortening of the right leg. Subsequently painful arthritis developed in the left knee, and recurred after synovectomy.

B Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from 364 ANNALS OF THE RHEUMATIC DISEASES This "long leg arthropathy" is a pattern of joint DR. CAMPBELL-SMITH: Yes, I think that this is a valid involvement of obvious importance in the under- criticism of our title. standing of our treatment of joint diseases and the DR. W. R. M. ALEXANDER (Edinburgh): I was unclear prevention of deterioration. of the incidence of this symptom complex, because in your first survey you had 33 people with shortening of one We are indebted to Mr. A. L. Eyre-Brook at Winford leg, chosen because they had 2 cm. of shortening or more Hospital and to our colleagues in the Bath Group and pain in the knees. This means you would automa- Hospitals for permission to survey the patients under tically select the ones with the symptom complex. their care. DR. CAMPBELL-SMrrH: We did not select them in that DISCUSSION sense. They complained of pain in either of the knees or both, and we did think we were going to go against the DR. D. A. BREWERTON (London): The term "long leg thesis until we found that those with pain in the "shorter" arthropathy" makes it appear that the disparity between knee were nearly all patients who had classical referred the lengths of the legs is responsible for the clinical pain. picture, whereas the gait shown in the film suggests that the primary problem is deformity of the hip or hips. DR. W. R. M. ALEXANDER: I meant there must be Patients attending Leg Equalization Clinics with long people who have one leg longer than the other but who or short legs due to other diseases do not walk in this do not have pain in the knee. I just wondered what the way and it is not known whether they develop similar incidence of the long leg arthropathy was amongst people degenerative changes. It would not be difficult to find who had one leg longer than the other. out in a Leg Equalization Clinic whether there is an DR. CAMPBELL-SMITH: That figure was not mentioned. altered incidence of degenerative joint disease. Without Speaking from memory, there were forty or fifty patients this information I do not think we are justified in calling in the Winford survey who had the required leg length this "long leg arthropathy". inequality but complained of no symptoms.

REFERENCES copyright. Castillo, B. A., El Sallab, R. A., and Scott, J. T. (1965). Ann. rheum. Dis., 24, 522 (Physical activity, cystic erosions, and osteoporosis in rheumatoid arthritis). Coste, F., and Forestier, J. (1935). Bull Soc. mid. H6p. Paris, 51, 772 (Hemiplegie et nodosites d'Heberden contralaterales). Courtright, L. J., and Kuzell, W. C. (1965). Ann. rheum. Dis., 24, 360 (Sparing effect of neurological

deficit and trauma on the course of adjuvant arthritis in the rat). http://ard.bmj.com/ Glyn, J. H., Sutherland, I., Walker, G. F., and Young, A. C. (1966). Brit. med. J., 2, 739 (Low incidence of osteoarthrosis in hip and knee after anterior poliomyelitis: a late review). Jacqueline, F. (1953). Rev. Rhum., 20, 323 (Un cas de polyarthrite evolutive a localisations contrala- terales d'une hemiplegie). Kamermann, J. S. (1966). Ann. rheum. Dis., 25, 361 (Protective effect of traumatic lesions on

rheumatoid arthritis). on October 2, 2021 by guest. Protected Lindsay, J. (1913). "Gout: its aetiology, pathology, and treatment", p. 109. (Oxford Medical Manuals). Hodder and Stoughton, London. Rot6s Qu6rol, J., and Roig-Escofet, D. (1968). Rev. Rhum., 35, 21 (Debut de l'arthrite rhumatoide. etude de 68 cas vus la premi6re ann6e d'evolution). Secondo, G., Barboso, B., and Mellini, M. (1967). Reumatismo, 19, 50 (Asymmetrical rheumatoid arthritis following poliomyelitis). Soila, P. (1963). Acta rheum. scand., 9, 264 (A roentgenological study of asymmetry in rheumatoid arthritis). Thompson, M., and Bywaters, E. G. L. (1962). Ann. rheum. Dis., 21, 370 (Unilateral rheumatoid arthritis following hemiplegia). Van Dam, G. (1964). In "Radiological Aspects of Rheumatoid Arthritis, Amsterdam, 1963". Excerpta Med. Foundation, Int. Congr. Series, No. 61, p. 63. Ann Rheum Dis: first published as 10.1136/ard.28.4.359 on 1 July 1969. Downloaded from LONG LEG ARTHROPATHY 365

L'arthropathie due 'a une longue jambe Artropatia de pierna larga RtSumE SUMAIuO "L'arthropathie causee par une longue jambe" se La "artropatia de pierna larga" se refiere a un tipo de refere a un ensemble de dommages aux articulations chez lesiones de articulaci6n visto en pacientes que caminan les malades qui marchent pendant un certain temps avec durante cierto tiempo con desigualdad incorrecta de des jambes de longueurs diff6rentes sans aucune correc- largo de piema. La rodilla de la pierna "ma's larga" tion faite au pr6alable. Le genou de lajambe plus longue esta' expuesta a dafios prematuros y mAs severos. Esto est expose de meilleure heure a des dommages plus severes. ocurre en casos de etiologia variada, entre ellos la Ceux-si sont d6montres par les cas d'6tiologie variee, tels artritis y la artrosis. Esto esti apoyado por dos que l'arthrite et l'arthrose. I1 est corrobor6 par deux estudios, en gran escala, de pacientes que asistian a releves de grande envergure des malades soign6s aux hospitales para reumaticos y hospitales ortopedicos. hopitaux orthopediques et rhumatismaux. Esta "artropatia de piema larga" es un patr6n de Cette "arthropathie causee par une longue jambe" est afecci6n articular de evidente importancia para com- un ensemble d'affection articulaire d'importance mani- prender nuestro tratamiento de enfermedades de las feste dans la comprehension de notre traitement des articulaciones y de la prevenci6n del empeoramiento. maladies articulaires et des mesures pr6ventives. copyright. http://ard.bmj.com/ on October 2, 2021 by guest. Protected