George V Russell, MD University of Mississippi Clamshell Osteotomy George V Russell, MD University of Mississippi

Objectives Framework Evolution/rationale Implementation Evaluation

Axes

Angular Deformities

Osteotomy Basics

Malunion: Deformity IR ER CORONAL SAGITTAL AXIAL MEDIAL LATERAL TRANSLATION MEDIAL LATERAL ANTERIOR POSTERIOR SHORTENED LENGTHENED ANGULATION VARUS VALGUS FLEXION [PROCURVATUM] EXTENSION [RECURVATUM] IR ER So you think about translation and angulation in the coronal, sagittal, and axial planes. And you decide that by the nature of its intramedullary position and its inherent strength through design and material properties, it should be pretty good at controlling deformity in the coronal and sagittal planes. It will be hard for the bone to deform by translation or angulation because you have a good fit between the implant and the bone on each side of the fracture. But the axial plane worries you…and for good reason.

MULTIAPICAL DEFORMITIES MULTILEVEL SOLUTION Osteotomy per CORA Other Muy complicado Compliments of Jeff Mast, MD

Single Cut Solution

TA, 43 yo male

Your Approach? Closing Wedge Single-Cut Dome/ Crescentic Opening Wedge Milch

Brilliance

JH Desperation

IMN for Osteotomies

Nail as Reduction Tool

Clamshell Osteotomy Simple planning

Clamshell/Conchas

Clamshell Osteotomy

Clamshell Osteotomy

TA, 43 yo male Preop osteotomy

TA postop osteotomy

TA 3 mos post osteotomy

TA 1 yr postop 2 yrs postop

BT, 53 yo female

BT, postop

BT, 10 mos

Materials and Methods 3 Medical Centers IRB approved Complex diaphyseal malunions 4 femoral malunions 6 tibial malunions

Materials and Methods All deformities post-traumatic Deformity 18 years (1-50 years) Avg age 41years (14-71 years) 7 males, 3 females

Results Independent Evaluation Osteotomies healed by 6 months

Radiographic Corrections Coronal: 2-20 degrees Sagittal: 0-32 degrees Axial: 0-25 degrees Length: 0-5 centimeters Within 2cm contralateral limb

Complications Delayed union—dynamization Broken interlocking bolt 2 wound dehiscences Local wound care D&I, closure

Clamshell Osteotomy: A New Technique to Correct Complex Diaphyseal Malunions Journal of Bone and Joint Surgery (American). 2009;91:314-324.

DJ, 40 yo female

DJ, postop 4th year resident

EG, 38 yo male Preop osteotomy recurvatum posterior translation varus shortening Preop osteotomy

EG Postop osteotomy

EG--4 years

EM, 60 yo male Longstanding malunion HTN Fall

EM postop

EM 6 mos postop

EM—1 yr

EM--3 years

Contraindications Morbid obesity Intramedullary osteomyelitis Short metaphyseal segment No intramedullary canal

Why I Like Clamshell Planning is simple Nailing is familiar Nail as reduction device Technique is transferable

Thank You The Miracle Center