malunions: principles of evaluation & treatment clifford b jones, md orthopaedic associates of...
TRANSCRIPT
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Malunions:Principles of Evaluation &
TreatmentClifford B Jones, MD
Orthopaedic Associates of MichiganClinical 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 >10 degrees after tibia fx
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Planes of deformity
Articular(splits and depressions!)
Length
Angulation
Rotation
Combined
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EvaluationLength– 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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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 osteotomyDefine plane of
deformity
Oblique cut
Rotate through cut
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16 F, 2 years s/p Flex IMN for Proximal Third Femoral FractureShort, 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 & OsteomyelitisNow, complaining of knee and tibial pain with activities
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Single Cut OsteotomyOsteotomy Fibula
Lag screw compressionMedial Plate Stabilization
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Multiplanar osteotomies
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Closed Femur IMN x 3Valgus
Short 3.5 cm
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Planning & Reduction
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1 year post op1 year post op
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IMN transverse osteotomy
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IMN, ORIF, Multiple Intramedullary Osteotomies
Short 2.5 cmPainful 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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“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 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 Osteotomy
Derotate 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 obtained:Return to OR
Insert 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 problemsIdentify the problem
Determine the consequences(with or without intervention)
Plan the correction
Execute the plan
Lifelong learning
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