malunions: principles of evaluation & treatment clifford b jones, md orthopaedic associates of...

Malunions:Principles of Evaluation &

TreatmentClifford B Jones, MD

Orthopaedic Associates of MichiganClinical Professor, MSU/CHM

Grand Rapids, MIMay 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

EvaluationLength– 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 osteotomyDefine plane of

deformity

Oblique cut

Rotate through cut

16 F, 2 years s/p Flex IMN for Proximal Third Femoral FractureShort, Varus, Apex Anterior, Painful Lateral Thigh Deformity

PRE OP PLAN

54 M, 13 years s/p Open tibial Fx & OsteomyelitisNow, complaining of knee and tibial pain with activities

Single Cut OsteotomyOsteotomy Fibula

Lag screw compressionMedial Plate Stabilization

Multiplanar osteotomies

Closed Femur IMN x 3Valgus

Short 3.5 cm

Planning & Reduction

1 year post op1 year post op

IMN transverse osteotomy

IMN, ORIF, Multiple Intramedullary Osteotomies

Short 2.5 cmPainful 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 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)

Remove IMN & Ream CanalIntramedullary Osteotomy

Derotate Leg – 45 Internal Rotation

Insert IMN – No Dist ILApply Uniplanar & Unicortical

External FixatorBegin Distraction Osteogenesis

When desired length obtained:Return to OR

Insert Distal IL ScrewsRemove External Fixator

Mid & Ending Distraction

Final Result

End Result

Complex problemsIdentify the problem

Determine the consequences(with or without intervention)

Plan the correction

Execute the plan

Lifelong learning

Thank You

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Questions/Comments

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