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

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

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

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