S-Malunion - Principals and Management
S-Malunion - Principals and Management
and Management
PRESENTER : Dr CHINTAN N
PATEL
Etiology:
• Failure of nonoperative treatment
• Failure of operative treatment
– incomplete surgical correction
– inadequate stability of fixation
– noncompliance of the patient
Importance of Limb Alignment
Detrimental effects of malalignment
Immediate
Functional limitations
Pain
Chronic
Joint related ( arthritis)
Management Overview
• Anatomical assessment
– Limb
» assessment of deformity
» status of surrounding joints
• Patient expectations
• Surgeon experience
Management - History and Physical
Examination
• Injury • Soft-tissues status
– mechanism – incisions
– energy – Defects
CT - scanogram
– rotational / length deformities
MRI
– intraarticular pathology
Assessment of Limb Alignment
• joint function
• alignment
• soft tissues
• limb length
Deformity Correction
General Considerations:
• Functional assessment – disability
• GOAL: Anatomical correction of deformity
• UL - upto 3 to 4 cm shortening well
tolerated.
• LL – upto 2 cm shortening treated with
Shoe Raise.
Timing for Deformity
Correction
• Extra-articular - controversial
• Intra-articular - ASAP
Surgical Overview
Preoperative Plan: selection of ,
• surgical approach / exposure
• osteotomy - location / type
• fixation technique(s)
• intraoperative use of,
– femoral distractor
– bone graft / substitute
Surgical Overview
Osteotomy
• site of deformity
• closed vs open
• simple vs multi planar
• technique -
– Predrill / osteotome
– Saw (irrigate)
Osteotomy
Type of deformity Type of osteotomy
length Transverse
rotational Transverse
angular Oblique
Wedge(opening/closing)
complex Bi- / Tri- planar
Crescentic (Dome)
Intraoperative Fixation
• Open fixation:
– If stable - IM nail vs plate vs circular
fixation
– lag screw with plate
• Closed fixation:
– IM nail
– percutaneous plate
– circular fixation
Examples
Proximal humerus
Distal radius
Proximal femur
Femoral shaft
Tibia
Ankle
Distal Humerus
Clavicle
1. Proximal Humerus
Deformity:
– varus
– extension
Problem:
– reduced ROM
– impingement
Treatment:
– Osteotomy:
» Biplanar
Fixation:
– Blade plate
2. Distal radius
42 year male
Swollen arm: x-rays
taken, conservatively
treated with cast
Healed at 8 weeks: Complaints of
wrist and DRUJ pain, decreased motion
Correction of post-traumatic wrist deformity in adults
by osteotomy, bone-grafting, and internal fixation.
Fernandez DL, JBJS 64(8), 1982
Osteotomy, bone graft and
fixation
3. Proximal Femur
• Following femoral
neck fracture:
– Varus Malunion
– AVN
• Treatment:
– valgus intertrochanteric
osteotomy
• Fixation:
– blade plate
Femoral Diaphysis Malunion
• Most common
– rotation and/or
– length
• Preop CT
– Determines rotational
malalignment
• Osteotomy with
IM saw
• Stabilization
– IM nail/plate
4. Tibial Diaphysis Malunion
Definition:
Controversial!!
• Shortening > 1cm
• Varus > 5º
• Valgus > 5 - 10º
• Internal / External rotation > 5 - 10º
• Recurvatum / Procurvatum > 10º
Tibial Diaphysis Malunion
Options for Fixation:
• IM Nail
• Plate
• Circular Fixator
Case Example
35 year female
•closed tibia fracture
•Cast immobilization
•healed
•complains of “toe
turned out”
Case Example
•Deformity:
– 20º external
rotation
– 10 º procurvatum
– 5º varus
•Confirmed:
– clinical exam &
CT scanogram
Case Example
•Osteotomy of tibia:
– biplanar transverse:
» closing anterior
& lateral wedge
and derotation
» oblique
osteotomy of
fibula
•Fixation:
– periarticular plate
5. Malunion of Ankle Fractures
Radiographic exam
Malunion Ankle Fractures
STEPS:
» fibular osteotomy - assess length
» osteotomy medial malleollus and/or
post malleollus if necessary
» reduce syndesmosis / joint
» temporary fixation
» stabilize fibula
6. Malunited Humerus
CUBITUS VARUS
“Gun-stock
Deformity” –
Looks like a
loading stock of
old long barrel
guns
TREATMENT
Lateral closing wedge osteotomy
Easiest
Safest
Most stable inherently
Medial open wedge osteotomy with
bone graft
Oblique osteotomy with derotation
CUBITUS VARUS
Modified French
French Osteotomy Osteotomy
(Bellemore)
Post. Longitudinal approach Posterolateral approach
Detach whole of triceps Lateral half of triceps
Ulnar nerve explored detached
Medial cortex broken Ulnar nerve Not explored
Medial cortex intact so
more stability
7. MALUNITED CLAVICLE
Double- osteotomy planned and practiced on solid
Real Bone models
Planned correction
Abnormal clavicle
Treatment Plan
• Tibia
shaft # -
Malunion Treatment
• Goals
– Improve function
– Decrease pain
– Prevent arthrosis
• Conclusion:
Corrective osteotomy has a definite role in the
treatment of malunited fractures.
THANK YOU !