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Here I have given an overview of the sort of issues I treat in adults. It is not intended as an exhaustive list, neither as a proxy for sound medical advice. 

If you are unsure please get in touch for more advice about the best way forward to help you in your time of need. 

Limb Malalignment

Any limb that is not shaped optimally for it’s function can be said to be malaligned. Sometimes this can be quite marked, at other times it is a mild issue that creates problems over time.

Recently the impact of rotational malalignment has become clearer in the realm of adult surgery. Experts in limb correction have talked about this for a very long time and we are happy to see the information starting to filter through to a greater range of patients.

Limb malalignment can have many causes- the commonest for a new problem in adults is as a result of a trauma or injury. Some people have had childhood problems which carry through in to adulthood either because of not being treated when younger, needing more input in to adult life or an accumulation of problems through age. One example of these is Blount’s disease:


e.g. Blount’s disease

This is a disorder of the growth plate in the upper inner tibia (the bone below the knee). It results in changes in the angle at the knee and results in bowing of the leg that gradually gets worse as people grow. In many countries and populations it is neglected in childhood as it does not necessarily cause pain, but the damage to the knee in the long term can be very severe. Realigning the limb, even if the joint has started to be damaged correcting the limb alignment can preserve the knee for a long time, and makes any future work on the knee easier and last longer.


Limb Length Difference

Limbs usually grow the same length. If you look at 100 people, on average 70 of them will have a leg length difference- they just don’t know about it! A difference of up to 1.5cm can be tolerated throughout life without noticing it at all. Above this some people start to notice effects on either their back, hips or knees and can look for treatment. Much more than 2.5cm and the effects are more noticeable and there is better evidence for treatment. Having said that I have found that some patients with a combination of a mild rotational malignment and a very small length difference of even just 1cm can feel significant impact from this. Treating the two elements can lead to a big difference in how they feel.

The management of different leg length differences can be broken down into simple steps including internal shoe lifts, external shoe modifications or length modifying procedures (lengthening or shortening). Often the best use for each patient is best discussed on an individual basis.

Of course, we should never forget the impact that arm length difference can make to people’s life. For many people it causes little functional problems but can be a major cause of cosmetic or body image concerns if there is a difference in the arms.

The causes of limb length differences in adults are similar to those for malalignment. New onset problems in adults are usually the result of trauma or injury. Some people have ongoing problems from childhood that have either not been treated, or treated but the person wants a new treatment option. Very often people come with the adult accumulation of undiagnosed problems from childhood that have started to cause pain. A good example of this is Hemi-hypertrophy, which has been described in more detail below:


e.g. Hemi-hypertrophy

Sometimes the two sides of the body can grow at different rates. It is actually fairly common and can be quite mild. Although both the arm and leg on the affected side can be longer in length, it is often only noticeable in the leg. Treatment is usually given in the form of shoe lifts, or if noticed at the correct time, smaller surgery in childhood to stop the growth in the longer leg can equalise the limb lengths.

Occasionally the thickness of the arm or leg can also be different. This is harder to treat but can be discussed with a plastic surgeon if it becomes a problem in any way.


Trauma and Post-Traumatic problems

If a bone is fractured or broken, problems can develop such as healing the wrong shape (mal-union), no healing (non-union) or infection. These can result in the limb looking and functioning abnormally, resulting in pain or limitation in how much you can do. For the person who was fit and well beforehand this can really have a life changing effect on them physically and mentally.

For a quicker and longer lasting recovery you need treatment by an expert with the knowledge and understanding of how to achieve your goals in the most reliable way. Limb reconstruction surgeons are often the few in each region who are trained in advanced techniques that can save limbs after injury and give you comprehensive treatment options.


Joint Malorientation

This is slightly different to limb malalignment. In this case the limb can remain the correct shape overall, so the arm or leg looks ok, but the angle of the joints causes pain and limited movement because they are set wrong. It is a bit like having the wheels on your car out of alignment. Of course, it can be associated with limb malalignment also and this is where the advice of an expert in limb alignment analysis and treatment becomes crucial to avoid having multiple operations or having operations that don’t give you the result you want.

The causes of adult joint malorientation are similar to the other areas above i.e. new injury or trauma, or the ongoing adult result of childhood problems such as injury, infection or congenital disorders. This time we have put the spotlight on infections:


e.g. Growth plate infection or injury

The growth plate is an area of cartilage near the ends of long bones. As children grow, the cartilage turns into bone, which determines the length and shape of the mature bone. The growth plates often also form the joints at the ends of the bones.

Injury here can result in the bone growth slowing down or stopping. If the whole growth plate stops you often land up with a limb the “correct” shape but short. If part of it stops then the limb will be misshapen resulting in malalignment or joint malorientation. Either of these, if severe enough can also result in poorly formed or shaped joints that go on to cause pain or stiffness in later life.


e.g. Meningococcal septicaemia

This is a very severe infection affecting children and young adults especially badly. It is caused by the bacterium Neisseria Meningitidis and when it gets in the blood stream can cause Septicaemia (blood poisoning) leading to a severe illness including loss of blood supply to skin, muscle and vulnerable parts of the skeleton in small children who still have a lot of growing to do. This can cause major problems with bone shape and length throughout childhood and the effects can be lifelong.


Bone Infection (Osteomyelitis)

Infection can result when bacteria or fungi get in to a bone. In adults bone infections most commonly occur after a trauma, injury or previous surgery. Joint infections can also occur, particularly in those with other medical problems.

Bone infections can appear quickly or develop over a long period of time. If they’re not properly treated, bone infections can leave a bone permanently damaged resulting in pain, long term leaking wounds or limitation in function. It is an area that limb reconstruction surgeons are very familiar with and can give you a comprehensive treatment plan for the long term.



Height Problems

A controversial topic to many, but height problems are real. The world is really designed in a very certain way that does not easily take in to account the needs of all members of our society.

Many people who have concerns about their height have been born with a skeletal dysplasia that limits how much their body can grow, others are unhappy with their height for a variety of personal, social, psychological or career reasons.

The options for treating height problems have changed dramatically in the last few years specifically. It is becoming easier to add height to patients, although there are still significant risks.

One of the bone shape diagnoses that can affect height in adulthood is Achondroplasia:


e.g. Achondroplasia

This is the most common type of short stature affecting how the arms and legs develop leading to either different shaped limbs or an overall reduction in height that some people find unsatisfactory. I can discuss your options in terms of your current function, the long term effects of the shape of your arms or legs on your joints and potential or active pain that you have. We can also discuss your height needs and options at your discretion.


Vascular Malformation

Vascular malformations are very common. They can range anywhere from a small “birth mark” to whole limbs or even half the body being affected. They can get inside joints, cause problems around them, make limbs grown long or short or take up space in bones that really should be packed full of nice honeycomb bone.

It is a specialist area in it’s own right, and the best services are made up of Dermatologists, Radiologists and Surgeons to take a rounded approach to managing the problem. There are few centres around the world who can manage them well and our unit at Great Ormond Street and the Wellington Hospital in London can manage these difficult cases for children or adults.

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