Ascending Functional Approach of the Skeletal System F. Landauer University Clinic of Orthopedics (PMU) Salzburg General Hospital Muellner Hauptstr. 48, 5020 Salzburg Austria Balancing of the spine Coronary Plane: Balancing of the spine over the disc L5-S1 (pelvis) without and in the brace Sagittal plane: Balancing to the plumb line: sacrum (pelvis),lumbar lordosis, thoracal kyphosis, cervical lordosis Horizontal plane: Rotation of the spine segments © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 2 Balancing of the sacrum (pelvis) Coronary plane (horizontal balancing of the sacrum) Leg length discrepancy (LLD) real (insoles, adapting of the shoes, orthoprostheses, etc.) functianal (physiotherapy, partial equalization of LLD, etc.) Sitting position non walker Sagittal plane (balancing of the sacrum) Balancing of the lumbosacral segment + cranial without and in the brace Free movement of the hip Horizontal plane (rotational balancing of the sacrum) Balancing of the lumbosacral segment + cranial without and in the brace © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 3 Feasibility of diagnosis Early onset scoliosis Adolescent scoliosis Adult scoliosis gray zone % gray zone Age © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 4 1st step: make the sacrum horizontal KING-classification LENKE-classification The sacrum is always horizontal © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 5 „Leg Length discrepancy“ LLD Compensation with an insole Heel Pad © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 6 Leg length discrepancy – scoliosis? S. L. 27.2.2001 It do´s not look like a typical AIS © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 7 Leg length discrepancy – scoliosis? It looks like a AIS Equalization of the leg length discrepancy © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 8 1st step: make the sacrum horizontal Treatment of Leg length discrepancy LLD <1.5cm → insoles etc. 1cm to 2cm → Epiphysiodesis >2cm → Leg-lengthening © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 9 Is LLD a problem ? Eigene Studie: SOSORT 2013-Chicago The x-ray (upright ap-view) of 250 patients assigned with the diagnosis “idiopathic scoliosis” were retrospectively examined to leg length difference >1.0 cm. First question: How many patients showed scoliosis as a compensation mechanism of leg-length discrepancy? How many needed epiphysiodesis in differences >1.5cm. Second question: What causes of leg length discrepancy are found and what are the therapeutic consequences? 4 Patients with neurological findings were excluded. © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 10 First question: compensation mechanism First question: In 5 cases of the 250 examined assigned patients, scoliosis was a compensation mechanism of the leg length discrepancy. Leg length compensation (insole) was sufficient for spinal correction. In 3 cases with a leg length difference >1.5 cm a temporary epiphysiodesis was indexed. © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 11 Leg length discrepancy + Malalignement B.S.1.8.97 LLD + Genu valgum remove 15 month´s later Endresult © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 12 Leg length discrepancy – Treatment S.C.18.1.01 LLD + Hemisacralisation X-ray +1cm on the left © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 13 Second question: pathological findings Pathological findings in the lower extremity Malformation 1 showed hypoplasia of the fibula (type 1A Achtermann and Kalamachi) 1 patient with hypoplastic femur (type IX by Pappas) could be diagnosed Trauma 1 patient had a femoral fracture in the early childhood, 1 patient suffered from an injury of the growth plate of the femur Tumor like leasion 1 patient showed a fibrous dysplasia + myxoma Hormonal problems 3 patients had ftreatment with hormons © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 14 Second question: pathological findings Pathological findings at the hip 2 cases a chronic slipped capital femoral epiphysis could be found and they needed surgical intervention. Additional hormonal causes as Hashimoto thyroiditis and delayed puberty were conspicuous. 1 patient a femoral head deformity after SCFE could be diagnosed and was corrected. 2 undiagnosed Perthes disease could be found. Many other diagnoses can influenze the lower extremities 4 patients with first diagnosed neurological findings are excluded. In 15 cases of 246 patients leg-length-discrepancy >1cm could be found and pathological findings differentiated. © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 15 LLD – Pathological findings R.D.08.07.96 Hypoplasia of the fibula Type 1A Achtermann and Kalamachi Future: Lengthening + Corretion of the with tibia insole ball in socket © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 16 LLD – Pathological findings F.R.5.4.99 What is the reason for the LLD ? We are not proud about the correction! Insole on the left +1.5cm © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 17 LLD – Pathological findings F.R.5.4.99 Fibrous dysplasia Insole on the left +1.5cm © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 18 LLD – Pathological findings F.R.5.4.99 Fibrous dysplasia + Myxoma MRI Myxoma Th10-11 Insole on the left +1.5cm © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 19 LLD – Pathological findings Fibrous dysplasia (Mb Jaffe-Lichtenstein) (monostotic or polyostotic) McCune-Albright Syndrome (with hormonal findings like hyperpigmentation, pubertas praecox) Mazabraud Syndrome Fibrous dysplasia + Myxoma Mutation of the G-protein © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 20 LLD – Pathological findings S.L.27.2.01 H.S.17.3.1996 R.J.1.6.2008 Defect of the growth plate Defect of the Femur with Hypoplasia shoelift right © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 21 LLD – Conclusion Message: LLD is an indicator for different diseases: Malformation Pathologie of the growth plate: Trauma, hypoplasia, misalignement, Perthes disease, epiphysiolysis (hormonal disease), etc. Tumor like leasions (genetic disease), etc. Scoliosis (The foot is a very good indicator for neurological findings) LLD can be treated very easy by Epiphysiodesis In case of scoliosis: Have an eye on the lower extemities. It reduces the number of „idiopathic“ scoliosis. © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 22 Hip – Pathological findings The connection between hip and the lumbar spine: Hip: Hip dysplasia Perthes disease Slipped Capital Femoral Epiphysiolysis Arthritis ec. Lumbar spine: Malformation Spondylolyis / -listhsis Degeneration: rigidity / instability etc. The ventral shape: Adipositas, etc. Neuromuscular disease Hip flexion contracture The foot as an indicator, etc. © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 23 Hip dysplasia R.A.21.2.74 Tripleosteotomie (Tönnis) © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 24 Malrotation + LLD (fractur of the femur as a young child) D.R.10.1.93 LLD: right +2cm Retrotorsion of the femur Norm: 12° Antetorsion NORM 12° Anteversion © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 25 Hip – L5-S1 (The twins) F.A.9.4.51 P.H.9.7.42 © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 26 The lumbar spine as a rotation center Funktional LLD © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 27 Hip – Pathological findings Case 1 Case 2 Perthes disease Hip adduction LLD Lumbar deviation © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 28 Hip + Malalignement + Hormons Sch.B.28.8.94 (10.a) Genu valgum Epiphysiodesis SCFE Slipped Capital Femoral Epiphysis Subcapital osteotomie Hashimoto thyreoiditis © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer