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malunion.pptx
- 1. Discuss the principlesand management of Malunion Dr P Shindang Orthopedic department NHA
- 2. Outline • Introduction • Etiology •Types of deformity • Classification • Management • Complications • Current trend • Local experience • Conclusion.
- 3. Introduction • Any bonethat does not heal in an anatomic position is a malunion. • It is consolidation of a fracture with shortening, malrotation or angulation producing unacceptable cosmetic deformity or significant functional deficit. • Bone alignment must be evaluated in terms of bone length, axial rotation and angulation in both the frontal and coronal planes
- 4. Etiology • Inaccurate fracturereduction • Insufficient fracture immobilization • Inadequate fracture fixation • Ill advised weight bearing • Injudicious intervention by traditional bone setters • Neglected fractures
- 5. Types of deformities •Angulation • Rotation • Translation • Leg length discrepancy
- 6. Classification • Based onthe Location • Intraarticular • Extra-articular – Metaphyseal – Diaphyseal • Combined • Plane malalignment – Simple – one plane – Complex - several plane and translation
- 7. Indications for Operativemanagement • Malunion with functional disability • Intra-articular malunion with joint instability • Mechanical overload • Capsulo-ligamentous strain • Cosmesis.
- 8. Management • Preoperative • History –Deformity – Pain – Mechanism of injury of initial fracture – History of previous intervention or no intervention – Functional limitations – Associated comorbidities
- 9. • Examination – Presenceof incisions, active drainage or sinus formation • Leg length discrepancy, evaluated • Rotational alignment should be determined compared with the normal side. – Malunion site • Stress to rule out motion • Stress to rule out pain – Range of motion of joints proximal and distal to malunion. – Neurovascular status of the limb
- 10. Investigation • Plain radiographs –AP, LAT, oblique • CT Scan with 3D recon – Evaluating rotational deformities • MRI – Intraarticular malalignment – Associated ligamentous injury • Laboratory investigations – FBC – CRP, ESR – HBA1c
- 11. Radiographic assessment • Objectives –Is there a deformity – Where is the deformity – What are the characteristics of the dformity
- 12. X-ray: bilateral fulllength standing AP and LAT views • Anatomical axis: – The anatomic axes are defined as the line that passes through the center of the diaphysis along the length of the bone. • Joint orientation lines: – describes the relation of a joint to the respective anatomic and mechanical axes of a long bone
- 13. • The mechanicalaxis: Defined as the line that passes through the joint centers of the proximal and distal joints.
- 15. • Center ofrotation of angulation(CORA) – The point about which a deformity may be rotated to achieve correction. – It is used to plan the operative correction of angular deformities.
- 16. Operative Treatment • AIM: –To correct translational, rotational and angular deformity – To achieve a functionally acceptable limb
- 17. Pre-Operative plan • PlannedSurgical approach/exposure • Osteotomy – location/type • Fixation techniques • Intraoperative adjuncts – use of bone graft/ bone substitute. – Image intensifiers
- 18. Intra op • Osteotomy –Site of deformity – Simple or multiplanar – Type of osteotomy
- 19. Osteotomy • Type ofdeformity • Length • Rotational • Angular • Complex • Type of osteotomy • Transverse • Transverse i. Oblique ii. Wedge(opening/closing) • Dome
- 20. Malunion: treatment bydeformity type • Length Discrepancy o Acute or gradual correction possible 1. Acute correction – Bone ends acutely distracted or compressed to desired length – Osteotomy stabilized with intramedullary nail or plate – Bone graft utilized in acute distraction 2. Gradual correction – Distraction thru corticotomy. Bone formed by distraction osteogenesis – Ex fix can correct all deformites simulatneously
- 21. • Angulation • Acuteor gradual correction possible – Acute correction • Dome osteotomies well suited for juxta-articular deformities • Wedge osteotomies work well in diaphyseal region • Osteotomy typically stabilized with intramedullary nail, plate or lag screws • Gradual correction – using external fixation to both restore alignment and provide stabilization during healing.
- 23. • Translation – Asingle transverse osteotomy may be made to restore alignment through pure translation – A single oblique osteotomy may be made at the level of the deformity to restore alignment and gain length. – Two wedge osteotomies at the level of the respective CORAs and angular corrections of equal magnitudes in opposite directions may be used to correct a translational deformity • Gradual correction may be carried out using external fixation.
- 25. • Combined deformities –often require gradual correction to allow adaptation of the bone,surrounding soft tissues and neurovascular structures. – The external fixator(Ilizarov) can be used to achieve correction of multiple deformity types in a single bone. – Taylor Spatial Frame which uses six telescopic struts, can be used to correct complex combined deformities.
- 27. Treatment by deformitylocation • Intraarticular malunion • Intraarticular osteotomies are salvage procedures that should be considered in symptomatic patients. • correction osteotomy • Arthrodesis • Arthroplasty
- 28. Complications • Under- andovercorrection • Nonunion • Neurovascular compromise • Delayed union • Failure of fixation • Infection • Thromboembolism • Joint stiffness
- 29. FOLLOW UP Aims: -Early detectionsof complications and treatment -Documentation of outcome -To fine tune management and skills • Duration, frequency and prognosis depend on: -Types of surgery -Stabilization device • History, examination and investigation at each follow up visit
- 30. case • A 35yrold female • Had closed distal tibia fracture • Managed nonoperatively • c/o toe turned out • Deformity – 20deg ext rotation – 10deg procurvartum – 5 deg varus
- 31. • Osteotomy oftibia • Closing anterior and lateral wedge and derotation osteotomy • Oblique osteotomy of fibula • Fixation – Distal medial tibial locking plate
- 32. Future trend • 3Dimaging – patient specific to guide osteotomy. • Arthroscopy-Assisted Corrective Osteotomy
- 33. LOCAL PERSPECTIVE • Facilities •Culture and beliefs • Quackery and TBS issues • Late presentation • Cost/insurance • Poor follow up
- 34. Conclusion • Management ofmalunions requires a sound understanding of the principles and biomechanics of internal fixation, the biology of fracture union, and the limits of the specific implants employed. • Due to the unique nature of each patient’s problem, patients with malunion require an individualized treatment plan with specific goals, being also be aware of potential complications.
- 35. References • Animesh A.Malunions, diagnosis evaluation and management. Springer, (2021) ch 1: introduction; p. 1-12 • Brinker MR, Oconnor DP. Basic sciences. In: Miller MD, ed. Review of orthopedics. Philadelphia, PA: WB Saunders; 2004 • Chapman, Michael W. Chapman's Orthopedic Surgery, 3rd Ed: Lippincott Williams & Wilkins 2001; p 848-888 • Richard E., Christopher G, Theerachai A, AO Principles of Fracture Management. Thieme; 2018; p 493-512 • Google images.
Editor's Notes
- #4 Malunion occurs when a fracture has healed in a position of deformity that results in a visible cosmetic deformity and/ or functional impairment.
- #8 In addition to malalignment, the treatment decision in extremity malunions must be made considering the patient’s age, activity level, functional demands, and medical status.