Malunions:
Principles of Evaluation &
Treatment
Clifford B Jones, MD
Orthopaedic Associates of Michigan
Clinical Professor, MSU/CHM
Grand Rapids, MI
May 2011
What is a malunion?
Bone healed in a nonanatomic position
– Affect function?
– Likely to affect function?
– Consequences with or without treatment
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
Planes of deformity
Articular
(splits and depressions!)
Length
Angulation
Rotation
Combined
Evaluation
Length
– Measure
– Blocks
– Scanogram
– CT scanogram
Evaluation
Angulation
– AP/lat X-rays
– Comparison views
– Long leg films
• Standing
Evaluation
Rotation
– Exam (rotational profile)
– CT
Evaluation
Rotation
– Exam (rotational profile)
– CT
Correction
Planning
Correction:
Closing wedge
Single site to heal
Biomechanically sound
Soft tissue friendly
Corrects angulation
May shorten
No graft required
Correction:
Closing wedge
Correction:
Closing wedge
Cut
Insert
Compress
Finalize
Correction:
Opening Wedge
Two sites to heal
Need graft
Tension soft tissue
– Pre op plan soft tissue integrity
Allows lengthening
Oblique osteotomy
Single site to heal
Large surface to heal
Compression at site
Can lengthen
No graft
Creates some rotation
Oblique osteotomy
Define plane of deformity
Oblique osteotomy
Define plane of deformity
Oblique osteotomy
Define plane of
deformity
Oblique cut
Oblique osteotomy
Define plane of
deformity
Oblique cut
Rotate through cut
Oblique osteotomy
Define plane of
deformity
Oblique cut
Rotate through cut
16 F, 2 years s/p Flex IMN for Proximal Third Femoral Fracture
Short, Varus, Apex Anterior, Painful Lateral Thigh Deformity
PRE OP PLAN
54 M, 13 years s/p Open tibial Fx & Osteomyelitis
Now, complaining of knee and tibial pain with activities
Single Cut Osteotomy
Osteotomy Fibula
Lag screw compression
Medial Plate Stabilization
Multiplanar osteotomies
Closed Femur IMN x 3
Valgus
Short 3.5 cm
Planning & Reduction
1 year post op
IMN transverse osteotomy
IMN, ORIF, Multiple
Intramedullary Osteotomies
Short 2.5 cm
Painful Lateral Thigh Deformity
IR Rotation Deformity 45°
2 Prior Failed ACL Recon
Multiple Intramedullary Osteotomies
Proximal
Osteotomy
Regenerate
Recanalization
Mid & Mid
Osteotomy
Distal Osteotomy
& Translation
ER Rotate
Translate
“Clamshell” osteotomy:
G. Russell, MD
“Clamshell” Osteotomy:
G. Russell, MD
“Clamshell” osteotomy:
G. Russell, MD
“Clamshell” osteotomy:
G. Russell, MD
“Clamshell” osteotomy:
G. Russell, MD
“Clamshell” osteotomy:
G. Russell, MD
Ilizarov Method
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)
Remove IMN & Ream Canal
Intramedullary Osteotomy
Derotate Leg – 45 Internal Rotation
Insert IMN – No Dist IL
Apply Uniplanar & Unicortical
External Fixator
Begin Distraction Osteogenesis
When desired length obtained:
Return to OR
Insert Distal IL Screws
Remove External Fixator
Mid & Ending Distraction
Final Result
End Result
Complex problems
Identify the problem
Determine the consequences
(with or without intervention)
Plan the correction
Execute the plan
Lifelong learning
Thank You
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