Type Of Malunion Research Articles

Unilateral external fixation of the tibial shaft malunion

Introduction/Objective. Fracture malunion is still a major problem in orthopaedic practice. The external fixation of tibial fracture malunion has become popular in recent years. The objective of this work was to evaluate clinical results in tibial shaft malunion treatment based on unilateral external fixation method. Methods. The patients with tibial shaft malunion have surgically been treated by unilateral Mitkovic external fixation system. Malunion deformities were corrected by ?one stage? technique, using Mitkovic-CD type external fixator, or gradually, using Mitkovic-V type external fixator. This retrospective study included 15 patients with tibial shaft angular malunion. The main type of malunion was valgus deformity, in 10 patients, and varus deformity, in five patients. Results. The mean healing time was 89.66 days (range 50?125). There were no complications in the present study. The follow-up time after surgery was three years. Final functional results were excellent in 13 cases and good in two cases. Conclusion. This unilateral external fixator system was successfully used in the treatment of tibial shaft malunion, with good results and low complications rate.

Comparative study of titanium elastic nailing v/s dynamic compression plating for the management of fracture shaft of femur in adolescent age group

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Femoral fractures are one of the common long bones fractured in paediatric age group. Over the past 20 years, there has been a dramatic and sustained trend toward the operative stabilization of femoral shaft fractures in school-aged children. Femoral fracture demands stable fixation in adolescent.</span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">A retrospective cohort study was conducted in a tertiary care hospital. All children’s between the age 11 to 18 years with femur fracture managed with either TENS or dynamic compression plating between march 2014 to march 2017 were included into the study</span>.<strong></strong></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">most common mode of injury was RTA. Middle third being the most common site for fracture. There was100% union in our study. The mean time of union in TENS group was 12 weeks and that of Plating group Was 13.1 weeks. Irritation at entry site was seen in 11 (22.9%) out of 48 patients. Malunion was seen in 9 out of 48 children’s in group a, whereas malunion in group b seen in 1 child. All the malunion was less than 5 degree and Varus being most common type of malunion. Limb length discrepancy in group A was observed in 5 patents (10.5%) out which 3 were shortening and 2 were lengthening. In group b 1pateint had shortening at end of follow up. In group B superficial infection was seen in 4 (15%) out of 33 children’s and in group A it was observed in 2 children’s (5%).</span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">we concluded that compression plating in adolescent age group especially older and obese children for the management fracture shaft of femur comparatively better than TENS.</span></p><p class="abstract"> </p>

Malunion of post-traumatic thoracolumbar fractures.

Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.

Three dimensional morphological evaluation of calcaneal fracture malunionand its clinical relevance

Objective To analyze 3D morphological evaluation of calcaneal fracture malunion based on CT post-processing techniques. Methods Eighteen patients with 19 calcaneal fracture malunion treated in our hospital from May 2010 to June 2015 were analyzed. The average age was 43.3 years (range, 23 to 62 years). There were 12 males (13 feet) and 6 females(6 feet). According to Stephens-Sanders classification, 3 feet were of type Ⅰ, 7 feet type Ⅱ and 9 feet type Ⅲ. Depending on the type of malunion and the preoperative evaluation of 3D morphology, the operation for the calcaneal fracture malunion was performed. The 3D structure of the calcaneus after shaded surface display reconstruction was extracted by interactive and automatic segmentation. The morphological measurements were achieved by means of a 3D measurement method. The data were analyzed using SPSS 18.0 software. The quantitative data were compared by paired t test. Results Making the telephone appointment for outpatient follow-up, all patients were followed up with an average time of 19.1 months. The mean AOFAS ankle-hindfoot score increased from (31.4 ± 6.1) point operatively to (77.4 ± 7.6) at final follow-up. The length of the calcaneal axis, the height of the posterior facet and the length of the posterior facet at final follow-up were significantly restored than those before operation (P<0.001). The mean Bohler′s angle and the mean Gissane′s angle were improved from (17.5° ± 5.6°) and (96.6° ± 9.9°) before operation to (34.2° ± 3.2°) and (124.1° ± 8.9°) at final follow-up respectively (P<0.001). Conclusion Three dimensional morphological evaluation of calcaneus was useful to access the postoperative outcome for calcaneal fracture malunion. The current data will be helpfulfor the reduction of calcaneal malunion. Key words: Calcaneus; Fracture, malunited; Image processing, computer-assisted; Imaging, three-dimensional

Categorization and surgical management of posttraumatic midfoot malunion

ObjectiveTo assess a classification system for midfoot injury that was based on the characteristics of the foot malunion and to evaluate the suggested treatment strategies.MethodsThis retrospective review of data from patients with posttraumatic midfoot malunion categorized each foot deformity into one of three types based on the foot arch and then separated these categories into one of three subtypes based on the forefoot deformity. According to the types of malunion, fascio-cutaneous flap, osteotomy, joint arthrodesis or realignment was used to correct the deformity. Patients were assessed before surgery and at 12 and 24 months postoperation.ResultsOf the 24 patients identified, six had Lisfranc joint injuries, nine had Lisfranc joint complex injuries combined with cuboid compression fractures and nine had Lisfranc joint complex injuries combined with navicular fractures. Overall, eight patients presented with poor soft tissue and massive scar at the dorsal foot. Visual analogue scale and American Orthopaedic Foot and Ankle Society midfoot scores significantly improved over the 24-month study period. At the end of the study, 21 of 24 patients (87.5%) rated their functional outcome as excellent or good.ConclusionThe classification of the midfoot malunion evaluated in this study may be helpful in the decision making process for surgical intervention.

Corrective osteotomies of the radius: Grafting or not?

To review the current literature regarding corrective osteotomies to provide the best evidence of the rule of bone grafting. Our MEDLINE literature search included 280 studies using the following key words "Malunited distal radius fracture" and 150 studies using key words "Corrective osteotomy of the distal radius". Inclusion criteria were: Malunited distal radial, extra articular fracture, volar locking plate, use of iliac bone graft (cancellous or corticocancellous), non-use of bone graft. Twelve studies met the inclusion criteria. Seven of the 12 studies considered, described the use of a graft; the remaining five studies didn't use any graft. Type of malunion was dorsal in most of the studies. The healing time was comparable using the graft or not (mean 12.5 wk), ranging from 7.5 to 16 wk. The mean disabilities of the arm, shoulder and hand score improvement was 23 points both in the studies that used the graft and in those not using the graft. This review demonstrated that corrective osteotomy of extra-articular malunited fractures of the distal radius treated by volar locking plate does not necessarily require bone graft.

The biomechanical effects of a deepened articular cavity during dynamic motion of the wrist joint

BackgroundA deepened articular cavity of the distal radius due to a metaphyseal comminution zone is associated with early osteoarthritis and reduced joint motion. As this deformity has not been investigated biomechanically, the purpose of this study was to evaluate the effects of a deepened articular cavity on contact biomechanics and motion range in a dynamic biomechanical setting. MethodsSix fresh frozen cadaver forearms were tested in a force controlled test bench during dynamic flexion and extension and intact mean contact pressure and contact area as well as range of motion were evaluated. Malunion was then simulated and intraarticular as well as motion data were obtained. Intact and malunion data were compared for the scaphoid and lunate facet and the total radial joint surface. FindingsDue to malunion simulation, cavity depth increased significantly. Motion decreased significantly to 54–69% when compared to the intact state. Malunion simulation led to a significant decrease of contact area in maximum extension for all locations (by ~50%). In maximum flexion and neutral position, contact area decrease was significant for the scaphoid fossa (by 51–54%) and the total radial joint surface (by 47–50%). Contact pressure showed a significant increase in maximum extension in the scaphoid fossa (by 129%). InterpretationAlready a small cavity increase led to significant alterations in contact biomechanics of the radiocarpal joint and to a significant range of motion decrease. This could be the biomechanical cause for degenerative changes after the investigated type of malunion. We think that restoration of the normal distal radius shape can minimize osteoarthritis risk post trauma and improve radiocarpal motion.

Three-dimensional assessment of zygomatic malunion using computed tomography in patients with cheek ptosis caused by reduction malarplasty

Reduction malarplasty is one of the most popular aesthetic surgical procedures for reshaping facial contour in oriental people. Especially for those who have a wide midface and a prominent zygoma. Although malunion and cheek ptosis are known as major complications in reduction malarplasty, but there have been few reports about their causes and patterns. The authors experienced many revision reduction malarplasty using the coronal approach to correct cheek ptosis with malunion and were able to categorize the types of malunion by analyzing 3-dimensional CT imaging prior to revision surgery. A total of 24 patients underwent revision reduction malarplasty with the coronal approach to correct the unfavorable result after primary malarplasty. Most patients complained of various degrees of cheek ptosis associated with malunion. In all cases, the status of zygomatic malunion was evaluated through 3D CT imaging. The operative procedures during revision surgery including repositioning of the inferolaterally displaced malar complex to the appropriate position and obtaining bone-to-bone contact with rigid fixation. If bony absorption at non-union margin was found during the operation, bihalved calvarial bone was grafted into the bony gap. Midface and forehead lifts were also performed when indicated. The types of zygomatic malunion could be categorized into four patterns according to the shape of displacement. The degree of displacement was relevant to the condition of the fixation in all cases. The higher the grade of malunion was evaluated in 3D CT imaging, the more difficult procedures it required during revision surgery. The postoperative results in all cases were satisfactory without any complications. In reduction malarplasty, inappropriate fixation and the ignorance of repositioning vector can lead to cheek ptosis and malunion by the action of masseter muscle. The malunion types apprehended by the preoperative 3D CT scanning enabled precise operative planning before revision surgery. In all grades of zygomatic malunion with cheek ptosis, revision reduction malarplasty with coronal approach was a very useful solution because it offers a wide surgical field, enables accurate repositioning along with firm fixation and easily allows simultaneous midface lift.

Total knee replacement in post-traumatic arthritic knees with limitation of flexion

The objective of this study is to investigate the results of total knee arthroplasty (TKA) in traumatic osteoarthritis cases with flexion restriction and to describe the technical details of their management. A multicentre series comprising 40 patients with limitation of flexion less than or equal to 90° was selected from 152 cases of post-traumatic knee arthritis with malunion. We hypothesized that the arthroplasty complication rate would be higher than in other etiologies of limitation of flexion and would require specific management strategies. In 23 cases, intra-articular malunion was present, in 15 cases extra-articular, and in two cases combined. The mean flexion was 72±23°, extension was 6±6°, and total range of motion (ROM) 66±23°. Eight cases of flexion restriction were severe (flexion<50°), six intermediate (flexion, 50-70°) and 26 moderate. In 14 cases, the anterior tibial tuberosity was osteotomized (43% intra-articular malunion and 6% extra-articular malunion). Five simultaneous realignment osteotomies were necessary. In severe cases of limitation of flexion, five extensive quadriceps releases were associated. Four mobilizations under general anesthesia were performed. In the cases of severe limitation of flexion, we noted three avulsions of the patellar tendon, two cases of cutaneous necrosis, one of which was associated with deep infection, and another case of deep infection. In the cases of moderate limitation of flexion, we noted one case of nonunion of the tibial tuberosity and two cases were revised for loosening, one aseptic and the other septic. With a mean follow-up of 5±4 years, the mean flexion was 99.4°±23 for a gain of 26.7±20°. The final flexion and the gain in flexion were correlated with preoperative flexion (r=0.62 and r=-0.47, respectively). The final amplitude was 99±27° for a gain of 33±21°. The flexion gains were comparable for both types of malunion, whether they were intra- or extra-articular. Arthroplasty provided a substantial gain in flexion. Osteotomy of the tibial tuberosity and the realignment osteotomies should be performed if necessary, with no risk of compromising the result. Superior gains can be sought in severe cases of limitation of flexion by releasing the extensor apparatus, in absence of cutaneous scar tissue retractions and recent infection. Level 4. Noncomparative retrospective study.

Endoscopic treatment of calcaneo-fibular impingement

The calcaneo-fibular impingement syndrome is frequent after calcaneal fracture and is linked to the decreased space between the tip of the fibula and the lateral wall of the calcaneus. The reasons for the painful symptoms are mixed with both bony and soft tissue involvement. The abnormal bony contact between the lateral calcaneal cortex and the tip of the fibula depends mainly on the size and localization of the lateral exostosis of the calcaneal wall. The soft tissue impingement is due to the fibrosis and scar tissues in the lateral gutter and to the compression of the peroneal tendons in the retromalleolar groove and under the tip of the malleolus. A 2-portal endoscopic technique is described for the treatment of calcaneo-fibular impingement with bone resection, soft tissue debridement and peroneal tendons release. One of the advantages of this endoscopic technique is the possibility of an assessment and treatment of associated lesions in the same procedure. A subtalar joint fusion can be done before if needed under arthroscopic control. As this endoscopic technique is very efficient to relieve symptoms of calcaneo-fibular impingement and is focused on the most relevant symptoms, it can thus be indicated for most of cases of calcaneal malunions, whatever the type of malunion and depending of the painful symptoms.

Intermediate to Long-Term Results of a Treatment Protocol for Calcaneal Fracture Malunions

Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery. Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021). This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.

INTERMEDIATE TO LONG-TERM RESULTS OF A TREATMENT PROTOCOL FOR CALCANEAL FRACTURE MALUNIONS

Background: Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. Methods: Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery. Results: Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021). Conclusions: This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Calcaneal malunions: results of a prognostic computed tomography classification system.

Following nonoperative treatment of calcaneal fractures, some patients may develop a disabling malunion with associated posttraumatic arthritis of the subtalar joint, impingement of the peroneal tendons, and hindfoot mal-alignment. We present a computed tomography classification system for calcaneal malunions which guides treatment and is of prognostic significance. A prospective study was performed using this classification system on a series of 26 malunions treated over a 45-month period. Three distinct types of malunions were identified: type I, lateral wall exostosis without subtalar arthrosis; type II, lateral wall exostosis with subtalar arthrosis; and type III, lateral wall exostosis, subtalar arthrosis, and a varus malunion. The surgical treatment was determined by a protocol based on the specific type of malunion encountered. Results were evaluated using the Maryland Foot Score. There were 18 excellent, 5 good, and 3 fair results. Although outcomes deteriorated as malunion complexity increased, significant clinical improvement as a result of reconstructive surgery was noted in even the worst types of malunion. This algorithm is consistent, prognostic, and useful for the orthopaedic surgeon presented with a symptomatic calcaneal malunion of one of these types.