malunion.pptx

principles of management of malunion
Malunion of fractures

1. Discuss the principles and 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 bone that 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 fracture reduction 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 on the Location Intraarticular Extra-articular Metaphyseal Diaphyseal Combined Plane malalignment Simple – one plane Complex - several plane and translation

7. Indications for Operative management 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 Presence of 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 full length 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 mechanical axis: Defined as the line that passes through the joint centers of the proximal and distal joints.

14. Center of rotation 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.

15. Operative Treatment AIM: To correct translational, rotational and angular deformity To achieve a functionally acceptable limb

16. Pre-Operative plan Planned Surgical approach/exposure Osteotomy – location/type Fixation techniques Intraoperative adjuncts use of bone graft/ bone substitute. Image intensifiers

17. Intra op Osteotomy Site of deformity Simple or multiplanar Type of osteotomy

18. Osteotomy Type of deformity Length Rotational Angular Complex Type of osteotomy Transverse Transverse Oblique Wedge(opening/closing) Dome

19. Malunion: treatment by deformity type Length Discrepancy Acute or gradual correction possible Acute correction Bone ends acutely distracted or compressed to desired length Osteotomy stabilized with intramedullary nail or plate Bone graft utilized in acute distraction Gradual correction Distraction thru corticotomy . Bone formed by distraction osteogenesis Ex fix can correct all deformites simulatneously

20. Angulation Acute or 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.

21. Translation A single 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.

22. 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.

23. Treatment by deformity location Intraarticular malunion Intraarticular osteotomies are salvage procedures that should be considered in symptomatic patients. correction osteotomy Arthrodesis Arthroplasty

24. Complications Under- and overcorrection Nonunion Neurovascular compromise Delayed union Failure of fixation Infection Thromboembolism Joint stiffness

25. FOLLOW UP Aims: -Early detections of 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

26. case A 35yr old female Had closed distal tibia fracture Managed nonoperatively c/o toe turned out Deformity 20deg ext rotation 10deg procurvartum 5 deg varus

27. Osteotomy of tibia Closing anterior and lateral wedge and derotation osteotomy Oblique osteotomy of fibula Fixation Distal medial tibial locking plate

28. Future trend 3D imaging – patient specific to guide osteotomy. Arthroscopy-Assisted Corrective Osteotomy

29. LOCAL PERSPECTIVE Facilities Culture and beliefs Quackery and TBS issues Late presentation Cost/insurance Poor follow up

30. Conclusion Management of malunions 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.

31. 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.