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Malunions: Principles of Evaluation & Treatment Clifford B Jones, MD Orthopaedic Associates of Michigan Clinical Professor, MSU/CHM Grand Rapids, MI May 2011
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What is a malunion? Bone healed in a nonanatomic position –Affect function? –Likely to affect function? –Consequences with or without treatment
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What is a malunion? Limits of deformity vary by bone and plane –Somewhat arbitrary –Merchant and Dietz, JBJS 1989 No long term effects on knee or ankle function at 29 years with deformity >10 degrees after tibia fx
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Planes of deformity Articular (splits and depressions!) Length Angulation Rotation Combined
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Evaluation Length –Measure –Blocks –Scanogram –CT scanogram
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Evaluation Angulation –AP/lat X-rays –Comparison views –Long leg films Standing
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Evaluation Rotation –Exam (rotational profile) –CT
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Evaluation Rotation –Exam (rotational profile) –CT
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Correction Planning
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Correction: Closing wedge Single site to heal Biomechanically sound Soft tissue friendly Corrects angulation May shorten No graft required
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Correction: Closing wedge
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Cut Insert Compress Finalize
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Correction: Opening Wedge Two sites to heal Need graft Tension soft tissue –Pre op plan soft tissue integrity Allows lengthening
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Oblique osteotomy Single site to heal Large surface to heal Compression at site Can lengthen No graft Creates some rotation
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Oblique osteotomy Define plane of deformity
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Oblique osteotomy Define plane of deformity
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Oblique osteotomy Define plane of deformity Oblique cut
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Oblique osteotomy Define plane of deformity Oblique cut Rotate through cut
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Oblique osteotomy Define plane of deformity Oblique cut Rotate through cut
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16 F, 2 years s/p Flex IMN for Proximal Third Femoral Fracture Short, Varus, Apex Anterior, Painful Lateral Thigh Deformity
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PRE OP PLAN
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54 M, 13 years s/p Open tibial Fx & Osteomyelitis Now, complaining of knee and tibial pain with activities
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Single Cut Osteotomy Osteotomy Fibula Lag screw compression Medial Plate Stabilization
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Multiplanar osteotomies
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Closed Femur IMN x 3 Valgus Short 3.5 cm
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Planning & Reduction
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1 year post op
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IMN transverse osteotomy
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IMN, ORIF, Multiple Intramedullary Osteotomies Short 2.5 cm Painful Lateral Thigh Deformity IR Rotation Deformity 45° 2 Prior Failed ACL Recon
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Multiple Intramedullary Osteotomies Proximal Osteotomy Regenerate Recanalization Mid & Mid Osteotomy Distal Osteotomy & Translation
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ER Rotate Translate
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“Clamshell” osteotomy: G. Russell, MD
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“Clamshell” Osteotomy: G. Russell, MD
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“Clamshell” osteotomy: G. Russell, MD
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Ilizarov Method
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Combination Method Osteotomy, Derotation, & Lengthening 45 M, Fall from ladder 18 mo prior Short Gamma IMN for Reverse Oblique Fx Pattern Began WBAT at 6 wks Complains of LLD (3.5 cm) and Inability to walk with his foot straight (45° ER Deformity)
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Remove IMN & Ream Canal Intramedullary Osteotomy Derotate Leg – 45 Internal Rotation
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Insert IMN – No Dist IL Apply Uniplanar & Unicortical External Fixator Begin Distraction Osteogenesis
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When desired length obtained: Return to OR Insert Distal IL Screws Remove External Fixator
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Mid & Ending Distraction
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Final Result
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End Result
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Complex problems Identify the problem Determine the consequences (with or without intervention) Plan the correction Execute the plan Lifelong learning
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Thank You E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org Return to General/Principles Index
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