Track 29: Malalignment and Various Methods of Correction

Subtrochanteric Malalignment and Various Methods of Correction

Introduction

Subtrochanteric malalignment refers to abnormal angulation, rotation, or displacement in the subtrochanteric region of the femur. This area, located just below the lesser trochanter, is subject to significant biomechanical stresses, making malalignment particularly challenging to treat. Causes include fractures, congenital deformities, metabolic bone diseases, or complications from previous surgeries.

Types of Subtrochanteric Malalignment

1. Angular Malalignment

   • Valgus or Varus Deformities: Lateral or medial deviations of the femoral shaft.
   • Sagittal Plane Deformities: Flexion or extension abnormalities.

2. Rotational Malalignment

   • Internal or external rotation deformities of the femoral shaft.

3. Shortening and Length Discrepancy

   • Resulting from fractures or improper healing.

4. Translation Malalignment

   • Lateral or anterior-posterior displacement of fragments.

Biomechanical Considerations

• The subtrochanteric region bears high compressive and shear forces due to its proximity to the hip joint and the attachment of strong muscle groups like the gluteus maximus and iliopsoas.
• Malalignment in this region significantly impacts gait, limb function, and joint loading, potentially leading to arthritis or compensatory deformities.

Methods of Correction

1. Conservative Management

   • Applicable for minimal deformities or non-displaced fractures.
   • Includes traction, bracing, and physiotherapy to restore alignment gradually.

2. Osteotomies

   • Corrective Osteotomies:
     • Angulation and rotational corrections via controlled bone cutting and realignment.
   • Types: Open-wedge, closed-wedge, or dome osteotomies.

3. Intramedullary Nailing

   • Preferred for its minimally invasive nature and biomechanical stability.
   • Allows angular and rotational corrections with controlled locking mechanisms.
   • Example: Antegrade or retrograde nailing techniques.

4. Plating Techniques

   • Useful for complex fractures or when intramedullary fixation is contraindicated.
   • Types: Dynamic compression plates (DCP), locking compression plates (LCP).

5. External Fixation

   • Indicated for severe open fractures or infected malunions.
   • Methods: Ilizarov or Taylor Spatial Frames for gradual realignment.

6. Hybrid Techniques

   • Combination of internal fixation with external support to address challenging cases.

Factors Influencing Treatment Choice

• Patient-Specific Factors: Age, bone quality, comorbidities.
• Deformity Characteristics: Type, location, and severity.
• Surgeon Expertise: Familiarity with techniques.
• Postoperative Goals: Functional recovery and prevention of complications.

Postoperative Considerations

• Regular follow-ups with radiographic evaluation.
• Physiotherapy to restore strength and range of motion.
• Addressing complications like hardware failure, infection, or nonunion.

Conclusion

Subtrochanteric malalignment is a complex orthopedic challenge requiring tailored interventions. Modern surgical techniques, combined with advanced imaging and planning, have significantly improved outcomes. A multidisciplinary approach involving orthopedic surgeons, physiotherapists, and rehabilitation specialists ensures optimal recovery and functional restoration.