ORTHOPAEDICS - Principals and management of Malunion with Examples

1. Malunion: The Principles
and Management
PRESENTER : Dr CHINTAN N
PATEL
CHAIR PERSON : Dr S.T.
SANIKOPDept of Orthopaedics , J.N. Medical College and
Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. Objectives
To understand:
• the definition of malunion
• the natural history of malunions
• the indications for treatment
• the surgical alternatives

3. Definition of Malunion
• Site
–upper vs lower extremity
–spine / pelvis
• Location
–intra-articular
–extra-articular
»metaphyseal
»diaphyseal
–combined
Malunion is defined as a healing of the bones in an
abnormal position

4. Definition of Malunion
• Types
–simple -
»skeletal malalignment
–complex -
»skeletal malalignment with,
»soft-tissue &/or articular abnormality

5. Definition of Malunion
• Direction
–angular
–rotational
–translation
–length

6. Malunion
Etiology:
• Failure of nonoperative treatment
• Failure of operative treatment
–incomplete surgical correction
–inadequate stability of fixation
–noncompliance of the patient

7. Importance of Limb Alignment
Detrimental effects of malalignment
Immediate
Functional limitations
Pain
Chronic
Joint related ( arthritis)

8. Management Overview
• Anatomical assessment
– Limb
» assessment of deformity
» status of surrounding joints
• Patient expectations
• Available Literature on expected outcome
• Surgeon experience

9. Management - History and Physical
Examination
• Injury
– mechanism
– energy
• Fracture
– location
– pattern
– bone loss
– ROM of
surrounding joints
• Soft-tissues status
– incisions
– Defects
• Previous treatment
– type
– stability
– complication(s)

10. Management: Investigations
Plain Radiographs
CT - scanogram
– rotational / length deformities
MRI
– intraarticular pathology

11. Assessment of Limb Alignment
Comparison with contralateral limb important

12. Assessment of Joint
Arthroscopy MRI

13. Alternates for Nonsalvagble Joint
• Debridement
• Arthrodiesis
• Arthroplasty

14. Biomechanical Principles
Effect of Surgery on:
• joint function
• alignment
• soft tissues
• limb length

15. 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.

16. Timing for Deformity
Correction
• Extra-articular - controversial
• Intra-articular - ASAP

17. Surgical Overview
Preoperative Plan: selection of ,
• surgical approach / exposure
• osteotomy - location / type
• fixation technique(s)
• intraoperative use of,
–femoral distractor
–bone graft / substitute

18. Surgical Overview
Osteotomy
• site of deformity
• closed vs open
• simple vs multi planar
• technique -
–Predrill / osteotome
–Saw (irrigate)

19. Osteotomy
Type of deformity
 length
 rotational
 angular
 complex
Type of osteotomy
 Transverse
 Transverse
 Oblique
Wedge(opening/closing)
 Bi- / Tri- planar
Crescentic (Dome)

20. 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

21. Examples
 Proximal humerus
 Distal radius
 Proximal femur
 Femoral shaft
 Tibia
 Ankle
 Distal Humerus
 Clavicle

22. 1. Proximal Humerus
Deformity:
– varus
– extension
Problem:
– reduced ROM
– impingement
Treatment:
– Osteotomy:
» Biplanar
Fixation:
– Blade plate

23. 2. Distal radius
42 year male
Swollen arm: x-rays
taken, conservatively
treated with cast

24. Healed at 8 weeks: Complaints of
wrist and DRUJ pain, decreased motion

25. Correction of post-traumatic wrist deformity in adults
by osteotomy, bone-grafting, and internal fixation.
Fernandez DL, JBJS 64(8), 1982

26. Osteotomy, bone graft and
fixation

27. 3. Proximal Femur
• Following femoral
neck fracture:
– Varus Malunion
– AVN
• Treatment:
– valgus intertrochanteric
osteotomy
• Fixation:
– blade plate

28. Femoral Diaphysis Malunion
• Most common
–rotation and/or
–length
• Preop CT
– Determines rotational
malalignment
• Osteotomy with
IM saw
• Stabilization
– IM nail/plate

29. 4. Tibial Diaphysis Malunion
Definition:
Controversial!!
• Shortening > 1cm
• Varus > 5º
• Valgus > 5 - 10º
• Internal / External rotation > 5 - 10º
• Recurvatum / Procurvatum > 10º

30. Tibial Diaphysis Malunion
Options for Fixation:
• IM Nail
• Plate
• Circular Fixator

31. Case Example
35 year female
•closed tibia fracture
•Cast immobilization
•healed
•complains of “toe
turned out”

32. Case Example
•Deformity:
– 20º external
rotation
– 10 º procurvatum
– 5º varus
•Confirmed:
– clinical exam &
CT scanogram

33. Case Example
•Osteotomy of tibia:
– biplanar transverse:
» closing anterior
& lateral wedge
and derotation
» oblique
osteotomy of
fibula
•Fixation:
– periarticular plate

34. 5. Malunion of Ankle Fractures
Radiographic exam

35. Malunion Ankle Fractures
STEPS:
»fibular osteotomy - assess length
» osteotomy medial malleollus and/or
post malleollus if necessary
» reduce syndesmosis / joint
» temporary fixation
» stabilize fibula

36. 6. Malunited Humerus
CUBITUS VARUS
“Gun-stock
Deformity” –
Looks like a
loading stock of
old long barrel
guns

37. TREATMENT
 Lateral closing wedge osteotomy
Easiest
Safest
Most stable inherently
 Medial open wedge osteotomy with
bone graft
 Oblique osteotomy with derotation

38. CUBITUS VARUS
French Osteotomy
 Post. Longitudinal approach
 Detach whole of triceps
 Ulnar nerve explored
 Medial cortex broken
Modified French
Osteotomy
(Bellemore)
 Posterolateral approach
 Lateral half of triceps
detached
 Ulnar nerve Not explored
 Medial cortex intact so
more stability

39.  Target normal clavicle
7. MALUNITED CLAVICLE
Double- osteotomy planned and practiced on solid
Real Bone models
 Planned correction
 Abnormal clavicle

40. Treatment PlanTreatment Plan
 Closing wedge osteotomy peformed
at mid-clavicle, bone wedge removed
 Opening wedge osteotomy
performed in lateral third, grafted with
bone wedge

41. BONE REMODELING in
CHILDREN
 Fractures close to ends of long bones
remodel much faster than fractures in
mid-shaft. Hence remodeling is faster
in PHYSEAL > METAPHYSEAL
>DIAPHYSEAL INJURIES.
 UL- most active growth plate is at
PROXIMAL HUMERUS AND
DISTAL RADIUS AND ULNA, hence
injuries of Proximal Humerus and
Wrist remodel faster than injuries of
elbow and proximal forearm.
 Inverse for the LL- remodeling is faster
at the Knee- Distal Femur and
Proximal Tibia than in Proximal
Femur and Distal Tibia.

42. ACCEPTABLE DEFORMITY
Distal Radius Metaphyseal # – 15 degrees of primary
angulation and 1cm of shortening in boys upto 14 years
and girls upto 12 years.
Radius-Ulna shaft # -upto 10 degrees of plastic
deformation acceptable.
Radius neck # -upto 30 degrees angulation, 2mm
translocation remodel.
Supracondylar Humerus # - upto 20 degrees angulation
in sagital plane remodel but no angular remodeling in
coronal plane
Humerus shaft # - 20 degrees angulation and upto 2 cm
bayonet shortening acceptable.

43. ACCEPTABLE DEFORMITY
• Femur
shaft # -
• Tibia
shaft # -

44. Malunion Treatment
• Goals
– Improve function
– Decrease pain
– Prevent arthrosis
• Conclusion:
Corrective osteotomy has a definite role in the
treatment of malunited fractures.

45. THANK YOU !