Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
J Bone Joint Surg Am. 2010 Sep;92 Suppl 1 Pt 2:158-75. doi: 10.2106/JBJS.I.01328.
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.
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.
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.
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.
复杂骨干愈合不良的治疗具有挑战性，需要广泛的术前规划和精确的手术技术。我们开发了一种更简单的方法来治疗其中一些畸形。
10 例复杂骨干愈合不良（包括 4 例股骨和 6 例胫骨愈合不良）行贝壳式截骨术。手术适应证包括邻近关节疼痛和畸形。手术显露后，将愈合不良的节段沿骨干垂直于近端和远端截断。截断的节段再次沿其长轴截骨并张开楔形，类似于打开贝壳。然后，使用髓内棒作为解剖轴模板，并使用对侧肢体作为长度和旋转模板，使骨干的近端和远端节段对齐。截骨术后平均 31 个月（6-52 个月）对患者进行临床和影像学评估。
所有病例均获得完全角度矫正；冠状面矫正程度为 2°-20°，矢状面为 0°-32°，轴向为 0°-25°（旋转）。长度矫正范围为 0-5cm，所有患者的肢体长度均恢复至 2cm 以内。所有截骨部位均在 6 个月时临床愈合。虽然没有深部感染，但 2 例患者沿截骨术的纵向部分切口出现浅表伤口裂开，强调了仔细处理软组织和选择患者的重要性。
贝壳式截骨术通过使用扩髓髓内棒作为模板重新调整长骨解剖轴，为纠正多种形式的骨干愈合不良提供了一种有用的方法。对于选择合适的骨干畸形患者亚组，这种技术可以减少术前规划时间和复杂性，降低术中截骨精度的要求。
