Malunions: Principles of Evaluation

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MalunionsPrinciples of Evaluation Treatment

• Clifford B Jones, MD
• Orthopaedic Associates of Michigan
• Clinical Professor, MSU/CHM
• Grand Rapids, MIMay 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 gt10 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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CorrectionClosing wedge

• Single site to heal
• Biomechanically sound
• Soft tissue friendly
• Corrects angulation
• May shorten
• No graft required

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CorrectionClosing wedge
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CorrectionClosing wedge
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Cut
Insert
Compress
Finalize
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CorrectionOpening 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 3ValgusShort 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
Mid Mid Osteotomy
Regenerate Recanalization
Distal Osteotomy Translation
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ER Rotate
Translate
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Clamshell osteotomyG. Russell, MD
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Clamshell OsteotomyG. Russell, MD
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Clamshell osteotomyG. Russell, MD
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Clamshell osteotomyG. Russell, MD
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Clamshell osteotomyG. Russell, MD
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Clamshell osteotomyG. Russell, MD
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Ilizarov Method
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Combination MethodOsteotomy, 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 CanalIntramedullary
OsteotomyDerotate Leg 45 Internal Rotation
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Insert IMN No Dist ILApply Uniplanar
Unicortical External FixatorBegin Distraction
Osteogenesis
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When desired length obtainedReturn to ORInsert
Distal IL ScrewsRemove 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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