Table Of ContentMalunions
Diagnosis, Evaluation
and Management
Animesh Agarwal
Editor
123
Malunions
Animesh Agarwal
Editor
Malunions
Diagnosis, Evaluation
and Management
Editor
Animesh Agarwal
Division of Orthopaedic Trauma
Department of Orthopaedic Surgery
UT Health
San Antonio, TX
USA
ISBN 978-1-0716-1122-7 ISBN 978-1-0716-1124-1 (eBook)
https://doi.org/10.1007/978-1-0716-1124-1
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At times our own light goes out and is rekindled by a spark
from another person. Each of us has cause to think with deep
gratitude of those who have lighted the flame within us.
– Albert Schweitzer
This book was completed amidst the COVID-19 pandemic of
2020 but began several years before. I am thankful to all the
authors who persevered over these past couple of years to
bring this book to fruition. The journey was difficult and the
end seemed unattainable, yet here we are. To Springer Nature,
namely Kristopher and Katherine, thank you for sticking with
me and seeing this through—I know it was frustrating and at
times painful.
I continue to have the most amazing parents, Jagdish and
Kusum, who have continued to be the best parents I could have
had and even better grandparents to my three children. They
continue to support me both professionally and personally.
My kids continue to amaze me especially during these last
three months of this crazy pandemic. They have been by my
side and understanding during my long hours, business trips,
and all my professional obligations. You three keep me going
and my fire burning. Thank you Priya, Deven, and Trevor for
being exemplary children in school and in life. I have never had
to worry about your choices although I always worry about
your well-being in this crazy world especially at this time.
I want to thank all those that have supported me
professionally as well. My 22 years here at the UT Health
certainly have been memorable. I have been extremely
fortunate to work alongside Drs. Charles A. Rockwood, Jr.,
James D. Heckman, and Fred Corley as well as with Drs.
Kyriacos Athanasiou and Mauli Agrawal. All of them believed
in me and gave me a chance as a medical student. I wouldn’t
be here without their faith in me. My fellowship training with
Drs. Attila Poka, Robert Ostrum, and Brian Davison was one
of the most memorable years of all my training and I am
forever grateful for all their advice, training, and support.
My interest in malunions was “ignited” by Dr. Charlie
Taylor who developed the Taylor Spatial Frame (TSF). It was
my introduction to the TSF and my involvement with TSF
courses over the last 20 years that kept the flame going and my
interest in the treatment of malunions. So, thank you, Charlie,
for your amazing device and all the knowledge and training
you have provided to many of us interested in malunion
surgery.
Last but not least, I would like to thank my administrative
assistant Anna Conti who has been with me for over 15 years of
my career. She is a true friend and always has been supportive.
Animesh Agarwal, MD
Boerne, TX, USA
July 2020
Foreword
Dr. Agarwal and his team of experts have created a thorough and very useful
textbook that can be employed quite efficiently to assess and treat fracture
malunions of all types. This work complements Dr. Agarwal’s earlier text-
book on nonunions and he has once again built upon the rich San Antonio
tradition begun by Rockwood and Green to clearly define the fracture prob-
lem and then provide, in an easily understandable manner, a roadmap for
treatment.
The chapters in this text cover all the anatomic areas and in every case are
written by experts in the field. In addition to thoroughly reviewing the litera-
ture, each author, or group of authors, brings a wealth of personal experience
to their chapter and presents the “Author’s Preferred Treatment” reflecting
that substantial clinical expertise. In addition, each chapter has a few repre-
sentative case examples that effectively illustrate the best treatment for these
challenging cases. The solutions each chapter describes are practical and
have proven to be effective in the hands of the experts. The reader will be well
served by the guidance provided in this textbook when he or she must decide
upon the best way to manage a malunited fracture.
Manchester, VT, USA James D. Heckman, MD
July 2020
vii
Preface
The only source of knowledge is experience.
– Albert Einstein
Despite modern fracture techniques and implants, malunions can still occur.
They can be quite disabling for the patient and challenging for the orthopedic
surgeon. Prevention by adhering to fracture fixation principles is the best way
to “treat” a malunion. The principles of malunion management vary accord-
ing to anatomical site, amount of deformity, functional limitations, and pain.
Iatrogenic causes are common but certainly avoidable to a certain degree.
Patient factors can come into play as well as injury factors that may make
anatomical restoration of length, alignment, and rotation problematic, lead-
ing to malalignment. Tips and tricks to restore the proper anatomy at the ini-
tial surgery can help to avoid primary malalignment from occurring.
Over the last 22 years of my practice, malunions have been challenging
but also very rewarding. Realigning a deformed limb after years of malalign-
ment is especially satisfying when the patient is able to walk better, their pain
resolves, and their overall function improves. This text was designed to pro-
vide a reference for the basic principles of malunion diagnosis, evaluation,
and management. Chapters are divided by anatomical area and common mal-
union situations are covered, but the principles of deformity analysis and
treatment decisions can be applicable to all types of malunions. There is no
one solution to each type of malunion, and treatment must be
individualized.
The contributors to this text were selected based on their interest and
expertise in this subject. Malunion management is learned by doing, and thus
surgeons have learned through years of performing these difficult operations,
oftentimes by trial and error. Their experience has become the knowledge
provided in this book. We hope that it provides the reader with a basis for
tackling these difficult problems.
Boerne, TX, USA Animesh Agarwal, MD
ix
Contents
1 Malunions: Introduction and Brief Overview . . . . . . . . . . . . . . . 1
Animesh Agarwal
2 Malunions of the Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Claudia C. Sidler-Maier, Laura A. Schemitsch,
Emil H. Schemitsch, and Michael D. McKee
3 Malunions of the Proximal Humerus . . . . . . . . . . . . . . . . . . . . . . 33
Christopher B. Hayes, Ryan L. Anderson, Gillian L. S. Soles,
and Philip R. Wolinsky
4 Malunions of the Humeral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Jacob J. Triplet and Benjamin C. Taylor
5 Malunions of the Distal Humerus . . . . . . . . . . . . . . . . . . . . . . . . . 87
Joseph Borrelli Jr., Tracey A. DeLucia, and Tsuyoshi Murase
6 Malunions of the Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Fred G. Corley and Ben S. Francisco
7 Malunions of the Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . 145
Matthew Lyons, Ahmad Fashandi, and Aaron M. Freilich
8 Malunions of the Acetabulum and Pelvis . . . . . . . . . . . . . . . . . . . 177
Kyle F. Dickson
9 Malunions of the Proximal Femur . . . . . . . . . . . . . . . . . . . . . . . . 215
Case W. Martin and Animesh Agarwal
10 Malunions of the Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Brian P. Cunningham, Peter A. Cole, and Gil Ortega
11 Malunions of the Distal Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Thomas L. Hand and Animesh Agarwal
12 Malunions of the Proximal Tibia and Tibial Plateau . . . . . . . . . . 313
Animesh Agarwal
xi
xii Contents
13 Malunions of the Tibial Shaft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Duc M. Nguyen and Stephen M. Quinnan
14 Malunions of the Distal Tibia and Ankle . . . . . . . . . . . . . . . . . . . 381
Kevin J. Pugh, B. Dale Sharpe Jr., and David B. Johnson Jr.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
