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The Clamshell Osteotomy: A New Technique to Correct Complex Diaphyseal Malunions

Russell, George V. MD; Graves, Matt L. MD; Archdeacon, Michael T. MD, MSE; Barei, David P. MD, FRCS(C); Brien, Glenn A. Jr. MD; Porter, Scott E. MD

Journal of Bone & Joint Surgery - American Volume: 01 February 2009 - Volume 91 - Issue 2 - p 314–324
doi: 10.2106/JBJS.H.00158
Scientific Articles
Supplementary Content

Background: The treatment of complex diaphyseal malunions is challenging, requiring extensive preoperative planning and precise operative technique. We have developed a simpler method to treat some of these deformities.

Methods: Ten patients with complex diaphyseal malunions (including four femoral and six tibial malunions) underwent a clamshell osteotomy. The indications for surgery included pain at adjacent joints and deformity. After surgical exposure, the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. The proximal and distal segments of the diaphysis were then aligned with use of an intramedullary rod as an anatomic axis template and with use of the contralateral extremity as a length and rotation template. The patients were assessed clinically and radiographically at a mean of thirty-one months (range, six to fifty-two months) after the osteotomy.

Results: Complete angular correction was achieved in each case; the amount of correction ranged from 2° to 20° in the coronal plane, from 0° to 32° in the sagittal plane, and from 0° to 25° in the axial plane (rotation). Correction of length ranged from 0 to 5 cm, and limb length was restored to within 2 cm in all patients. All osteotomy sites were healed clinically by six months. While no deep infections occurred, superficial wound dehiscence occurred in two patients along the approach for the longitudinal portion of the osteotomy, emphasizing the importance of careful soft-tissue handling and patient selection.

Conclusions: The clamshell osteotomy provides a useful way to correct many forms of diaphyseal malunion by realigning the anatomic axis of the long bone with use of a reamed intramedullary rod as a template. This technique provides an alternative that could decrease preoperative planning time and complexity as well as decrease the need for intraoperative osteotomy precision in a correctly chosen subset of patients with diaphyseal deformities.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail address for M.L. Graves:

2Department of Orthopaedic Surgery, University of Cincinnati, College of Medicine, P.O. Box 670212, 231 Albert Sabin Way, Cincinnati, OH 45267-0212

3Department of Orthopaedic Surgery, Harborview Medical Center, P.O. Box 359798, 325 9th Avenue, Seattle, WA 98104-2499

Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated
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