The Principles and

Management of Malunions

Peter Cole, MD
 Objectives
To understand:
• the definition of malunion
• the natural history of malunions
• the indications for treatment
• the need for preoperative evaluation
• the surgical alternatives
 Definition of Malunion
• Site
– upper vs lower extremity
– spine / pelvis
• Location
– intra-articular
– extra-articular
» metaphyseal
» diaphyseal
– combined
 Definition of Malunion
• Type
– simple -
» skeletal malalignment
– complex -
» skeletal malalignment and
» soft-tissue &/or articular abnormality
 Definition of Malunion
• Direction
– angular
– rotational
– translation
– length

*Requires knowledge of normal anatomical alignment

 Malunion
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)
Increased point contact forces
Chronic overload
Increased shear stress
* Requires knowledge of normal mechanical alignment
Anatomy
•Mechanical Axis
•Anatomical Axis
 Management Overview
Anatomical
– Limb
» assessment of deformity
» status of surrounding joints
– Soft -tissue status
» incisions
» previous sepsis
• Patient expectations
• Available Literature
- expected outcome of correction
• Surgeon experience
 Deformity Correction
Two most important factors:
Patient:
– compliance
– risk factors
– expectations
Surgeon:
– experience
– expectations
 Management - History

•Injury •Soft-tissues
– mechanism – incisions
– energy – deforming forces
– defects
•Fracture •Previous treatment
– location – fixation
– pattern – type
– bone loss – stability
– complication(s)
 Management – Physical Exam

• Skin
• Vascular
• Neurologic
• Range of motion of surrounding joints
• Contractures
– soft-tissues
– joints
• Site of pain
 Management: Investigations
Plain Radiographs
– multiplanar
– lower extremity - weight bearing/ long cassette
– normal side
CT - scanogram
– rotational / length
MRI
– intraarticular pathology
Assessment of Limb Alignment

Comparison with contralateral limb important

 Assessment of Joint
Arthroscopy MRI
Alternates for Nonsalvagble Joint
• Debridement
• Arthrodiesis
• Arthroplasty
 Biomechanical Principles
Effect of Surgery on:

• joint function
• alignment
• soft tissues
• limb length
 Deformity Correction
General Considerations:
• Key: Prevention with initial treatment
• Functional assessment - disability
• Indications for correction vary for
specific malunions
• AO principles:
– atraumatic soft tissue technique
– atraumatic reduction and fixation techniques
– appropriate fixation stability
– early active range of motion
 Deformity Correction
GOAL: Anatomical correction of deformity

Surgical Tactic
• Key: Preoperative Plan
– Understanding deformity
– Principles of operative correction
• Patient involvement
 Deformity Correction
Timing:

• Extra-articular - controversial

• Intra-articular - ASAP
 Surgical Overview
Preoperative Plan:
• surgical approach / exposure
• osteotomy - location / type
• fixation technique(s)
• intraoperative adjuncts:
– image intensifier
– femoral distractor
– bone graft / substitute
 Surgical Overview
Osteotomy Fixation
• site of deformity vs • plate
remote • IM nail
• closed vs open • External Fixator
• simple vs multi planar – ring
• technique - – unilateral
– 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)
 Osteotomy

Type Disadvantage Advantage

transverse unable to use lag easy, stable

Oblique difficult, unstable able to use lag

closing wedge more exposure req’d no bone graft

req’d
shortening stable

translation/rotation
lag screw
 Osteotomy
Type Disadvantage Advantage
opening wedge lengthening lengthening
bone graft
translation/rotation
unstable
unable to use lag
dome
difficult easy
more exposure stable

translation/rotation
able to use lag
no bone graft
 Intraoperative
Osteotomy: Open
• Incision: extensile
• K-wires ( reference for correction)
– rotatory
» perpendicular to long axis
– angular
» parallel to joint axis
• Predrilling
• Thin saw
• Cooling with irrigation
 Intraoperative
Osteotomy: Closed
• IM saw vs percutaneous
• remote from extensive callus
• percutaneous completion of osteotomy
 Intraoperative
Fixation:
• open:
– stable - IM nail vs plate vs circular fixation
– lag screw if possible with plate
• closed:
– IM nail
– percutaneous plate
– circular fixation
 Pitfalls
• Poor/inadequate understanding of deformity
• Inadequate preoperative plan
• Imprecise osteotomy
• Unstable / inadequate fixation
 Postoperative

• Early range of motion of joints (when possible)

• Timing of weight-bearing variable
 Examples
• Proximal humerus
• Distal radius
• Proximal femur
• Femoral shaft
• Tibia
• ankle
 Proximal Humerus

Deformity:
– varus
– extension
Problem:
– reduced ROM
– impingement
Treatment:
– Osteotomy:
» Biplanar
Fixation:
– Blade plate
 Distal radius

DP, 42 y.o. male

MVA, Closed Head
Injury, femur fracture
Swollen arm: x-rays
taken, 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
Pre-operative Plan
Osteotomy, bone graft and
fixation
 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
Scanogram
– Determines rotational
malalignment
• Osteotomy with
IM saw
• Stabilization
– IM nail/plate
 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

Choice influenced by previous treatment

 Case Example
35 yo female
•closed tibia fracture
•cast
•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
 Case Example

•Osteotomy of tibia:
– biplanar transverse:
» closing anterior
& lateral wedge
and derotation
» oblique
osteotomy of
fibula
•Fixation:
– periarticular plate
 Malunion Ankle Fractures
Radiographic exam
Malunion Ankle Fractures
STEPS:
» fibular osteotomy - assess length
» clean fibular groove, medial joint space
» osteotomy medial malleollus and/or
post malleollus if necessary
» reduce syndesmosis / joint
» temporary fixation - intraop xray
» stabilize fibula
Malunited Ankle Fractures

53 yo M
Malunited Ankle Fractures

6 wks
Post ORIF
 Malunited Ankle Fractures

1 yr post
reconstruction
Malunion

SUMMARY
 Malunion - Management Overview
Patient & Surgeon
Fixation expectations
and bone
graft Soft
Pre-operative decision tissues
making

Osteotomy
simple vs complex Intraarticular pathology
closed vs open
 Malunion
• Goals
– Improve function
– Decrease pain
– Prevent arthrosis
• Conclusion:
Corrective osteotomy has a definite role in the
treatment of malunited fractures

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