title: The clamshell osteotomy: a new technique to correct complex diaphyseal malunions.
abstract: 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 degrees to 20 degrees in the coronal plane, from 0 degrees to 32 degrees in the sagittal plane, and from 0 degrees to 25 degrees 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.
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
authors.forename: George V
authors.initials: GV
authors.lastname: Russell
authors.forename: Matt L
authors.initials: ML
authors.lastname: Graves
authors.forename: Michael T
authors.initials: MT
authors.lastname: Archdeacon
authors.forename: David P
authors.initials: DP
authors.lastname: Barei
authors.forename: Glenn A
authors.initials: GA
authors.lastname: Brien
authors.forename: Scott E
authors.initials: SE
authors.lastname: Porter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001858:Bone Nails; D001863:Bone Screws; D018483:Diaphyses; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D017102:Fracture Healing; D017759:Fractures, Malunited / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010027:Osteotomy / Q000295:instrumentation / Q000379:methods*; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D013978:Tibial Fractures / Q000601:surgery*; D055815:Young Adult