[Treatment of posttraumatic cubitus varus in children and adolescents. Supracondylar humeral osteotomy using radial external fixation]

Efficacy and Complications of External Fixator-Assisted Correction in Cubitus Varus Deformity

Background

Untreated cubitus varus results in cosmetic deformity as well as posterolateral rotatory instability at the elbow if longstanding. French osteotomy with its modifications is the most commonly done osteotomy and relies on a medial intact hinge and these osteotomies fail to address the lateral prominence. Intraoperative fixator assistance to adjust the translation and fine tune the osteotomy is a novel method to address the lateral prominence. This prospective study analyses the efficacy of the same.

Materials and Methods

A total of 16 consecutive patients presenting with unilateral cubitus varus resulting from mal-united supracondylar fracture of humerus were included. The humero-ulnar angle correction required, size of lateral closing wedge and amount of translation required were calculated. After a lateral surgical approach, one Schanz pin of size 2.5mm-3.5mm depending on age, was passed just above the level of distal humerus physis, lateral to medial; a second pin was inserted in the shaft of humerus, again lateral to medial. Pre-calculated wedge of bone was removed, angular correction as well as translation done; fine tuning of the osteotomy was achieved using fixator assistance. Rotational and hyperextension deformities were corrected simultaneously. Fixation of the osteotomy was done by multiple K wires or plates, depending on the age of the patient.

Observation and Results

The mean carrying angle corrected to 10.4 degrees valgus from a preoperative value of 19.8 degrees varus. The mean humero-ulnar angle corrected to 9.6 degrees valgus from a preoperative value of 19.6 degrees varus. The mean lateral prominence index reduced to - 3.8% from a preoperative value of - 5.5%. The mean cosmetic correction score was 9 (Max 10) from a preoperative value of 1.9. No patient had an 'S' shaped deformity in the operated elbow. No nerve palsies were observed in any of the operated patients.

Conclusions

Fixator assistance during surgery allows angular, translation and rotational control of the fragments to fully correct the deformity. It also allows fine tuning of the osteotomy during surgery.

Surgical correction of cubitus varus in children with a lateral closing-wedge osteotomy: a comparison between two different techniques

OBJECTIVES

The primary objective of the present study is to compare the radiographic outcomes and complications of two different techniques for lateral closing-wedge osteotomy in pediatric patients with cubitus varus.

METHODS

We retrospectively identified patients treated at five tertiary care institutions: 17 underwent the Kirschner-wire (KW) technique, and 15 patients were treated with the mini external fixator (MEF) technique. Demographic data, previous treatment, pre- and postoperative carrying angle (CA), complications and additional procedures were recorded. Radiographic evaluation included assessment of the humerus-elbow-wrist angle (HEW), and the lateral prominence index (LPI).

RESULTS

Patients treated with both KW and MEF achieved significant improvements in clinical alignment (mean pre-op CA -16 ± 6.1 degrees to mean post-op 8.9 ± 5.3 degrees, P < 0.001). There were no differences in final radiographic alignment or radiographic union time; however, time to achieve full elbow motion was faster in the MEF group (13.6 versus 34.3 weeks, P = 0.4547). Two patients (11.8%) in the KW group experienced complications, including one superficial infection and one failed correction that required unplanned revision surgery. Eleven patients in the MEF group underwent a planned second surgical procedure for hardware removal.

CONCLUSIONS

Both fixation techniques are effective at correcting cubitus varus in the pediatric population. The MEF technique may have the advantage of shorter recovery of elbow range of motion but may require sedation for hardware removal. The KW technique may present a slightly higher complication rate.

Comparative evaluation of pinning and cast fixation vs. external fixation after lateral closing-wedge osteotomy for cubitus varus in children

BACKGROUND

Cubitus varus has been regarded as a poor functional and cosmetic consequence of supracondylar humerus fracture in children. The aim of this study was to assess the clinical and radiologic outcomes of cubitus varus treatments based on fixation methods: Kirschner (K)-wire and cast fixation or external fixation.

METHODS

Forty consecutive patients with cubitus varus secondary to supracondylar fractures were retrospectively enrolled between October 2015 and December 2018. Following lateral closing-wedge osteotomy, those undergoing K-wire and cast fixation were included in group A (n = 21) and those who were treated with external fixation comprised group B (n = 19). We measured the bony union, elbow joint range of motion, and carrying angle. The clinical and radiographic results were assessed according to the Bellemore criteria.

RESULTS

No significant difference was found between the 2 groups in terms of age, gender, operation duration, union time, and postoperative elbow range of motion (P > .05). A significant difference was noted, however, in postoperative carrying angle and results according to Bellemore criteria in group B (P < .05). No nonunion, myositis ossificans, or neurovascular injury was found at follow-up in the 2 groups. In group A, revision surgery was needed for residual varus in 1 patient and lateral condylar prominence was found in 2 patients. In group B, a superficial pin-site infection occurred in 2 patients, who were treated successfully with oral antibiotics.

CONCLUSIONS

Both K-wire and external fixation after lateral closing-wedge osteotomy are reliable and effective for the treatment of cubitus varus in children. Compared with the K-wire method, external fixation achieves better functional and cosmetic results with a shorter learning curve.

Small incision reduction and external fixation for the treatment of delayed over fourteen days supracondylar humeral fractures in children

BACKGROUND

Supracondylar humeral fractures (SHF) are the most common type of fracture occurring at the distal humerus in children. In patients with delayed presentation of SHF, closed reduction is challenging to achieve with traditional reduction maneuvers. This study aimed to report the clinical results of pediatric SHF delayed over 14 days treated by closed reduction with a minimally invasive technique and external fixation and evaluate the efficacy of this technique.

METHODS

Between October 2010 and September 2018, children with delayed presentation of SHF over 14 days were retrospectively included in this study. The patients received closed reduction with a minimally invasive technique followed by external fixation. The demographics and radiographic data were collected. The Mayo Elbow Performance Score (MEPS) and the Flynn criteria were used to evaluate the clinical outcomes of treatments.

RESULTS

A total of 11 children (aged 4-13 years) with delayed presentation (range, 14-22 days) were recruited. They received surgery using closed reduction with a minimally invasive technique followed by external fixation. None of the surgery was done with the open method. After surgery, the patients' carrying angle returned to normal. The radiological union was evident in 8 to 12 weeks in all fractures without complications. Every patient had a good to excellent score on the MEPS and the Flynn criteria.

CONCLUSIONS

The results of this series indicated a satisfactory outcome in children with delayed more than 14 days of supracondylar humeral fractures. The closed reduction with a minimally invasive technique followed by external fixation is an alternative treatment for such injury.

[Typical liability damages of the upper extremities in childhood and their evaluation]

Legal appraisals of possible treatment errors in childhood and adolescence are rare, often refer to the treatment of trauma of the upper limbs and are frequently recognized. From the activity of the first author as an expert witness 31 expert opinions (25%) referred to the upper limbs. Supracondylar humeral fractures, radius neck fractures, radial condyle fractures and distal radius fractures were predominant. A primary treatment error was determined in 14 patients and a secondary error in 7 patients. This corresponds to a recognition rate of 68%. The aim of this study was the reflection and the development of a prevention strategy. Insufficient recognition of instability (radial condyle), inadequate reduction and inadequate stabilization (radius neck, supracondylar) as well as untreated malalignments and secondary dislocations (wrist) were the main reproaches. Poor communication and deficient documentation often aggravate the situation. Working along clear algorithms can help to avoid legal proceedings and assignment of guilt.

Comparison of internal fixation vs. external fixation after corrective osteotomy in children with cubitus varus

BACKGROUND

Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologic outcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities.

MATERIALS AND METHODS

From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patients who underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patients with unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria.

RESULTS

No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results.

CONCLUSIONS

In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal.

Increased incidence of distal humeral fracture surgery and decreased incidence of respective corrective osteotomy among Finns aged 0 to 18 years between 1987 and 2016: a population-based study

PURPOSE

Previous studies on paediatric and adolescent distal humeral fractures have reported an increase in surgical treatment activity. This increase could be hypothesized to reduce the incidence of corrective osteotomies. The aim of this study was to determine the incidence and trends of the primary surgical treatment of distal humeral fractures and corrective osteotomies in children and adolescents.

METHODS

All Finns 18 years of age or younger who underwent treatment for distal humeral fracture between 1987 and 2016 were included in this population-based study. Surgical treatment data were obtained from the National Hospital Discharge Register of Finland. In calculating annual surgery incidence rates, the annual mid-year populations were obtained from the Official Statistics Finland. Surgical treatment was categorized into four groups; reposition and casting, osteosynthesis, external fixation and corrective osteotomy.

RESULTS

During the 30-year study period, 9017 surgical procedures were performed in Finland with the primary or secondary diagnosis code being a distal humeral fracture. Of these, 6961 (77.2%) were osteosynthesis and the incidence of osteosynthesis (per 100 000 person-years) increased fourfold from 8.2 in 1987 to 34.1 in 2016. In the same 30-year study period, the total number of corrective osteotomies was low (151) with annual variation from one to 16. The incidence of corrective osteotomies (per 100 000 person-years) decreased sevenfold from 0.7 to 0.1.

CONCLUSION

The incidence of surgical treatment with osteosynthesis in distal humeral fractures increased fourfold in Finland between 1987 and 2016. During the same time period, the number of corrective osteotomies diminished significantly.

LEVEL OF EVIDENCE

IV.

[Corrective osteotomies around the elbow in childhood and adolescence : Indications and techniques for posttraumatic deformities]

Evidence-based literature on counseling and treatment of pediatric and adolescent patients with posttraumatic deformities is scarce; however, especially around the elbow with its low remodeling potential, the number of patients with malunions presenting in outpatient clinics is not rare at all. In this review the more frequent indications for corrective surgery around the pediatric elbow are described and treatment proposals are made from the perspective of an interregional reference center for pediatric and adolescent trauma.

Application of computer simulation in the treatment of traumatic cubitus varus deformity in children

Cubitus varus deformity is common in children. The purpose of this study was to assess the usefulness of computer simulation based on three-dimensional computed tomography (3D-CT) reconstruction with regard to preoperative planning and surgical treatment in children with traumatic cubitus varus deformity.The study included 13 patients with traumatic cubitus varus deformity between January 2012 and January 2015. The original 3D-CT data were transferred to Mimics 10.01 software. Special tools were used for simulation of supracondylar lateral wedge osteotomy of the humerus. Intraoperative elbow arthrography was used to identify the articular surface of the elbow joint for assisting the judgment of the osteotomy site. Kirschner wires were used to determine the osteotomy plane and angle. The osteotomy site was fixed by crossing Kirschner wires and steel wire tension band.Of the 13 patients, 11 were male and 2 were female. The left side was affected in 8 patients, and the right side was affected in 5 patients. The patient age ranged from 2 years to 14 years (mean age, 6 years and 7 months). The varus angle ranged from 12° to 35° (mean angle, 20°). The carrying angle on the contralateral side ranged from 5° to 18° (mean angle, 10°). The varus deformities showed good correction. The 13 patients were followed up for 24 to 60 months (mean follow-up, 38 months). According to the Flynn score of elbow joint function after surgery: 10 patients had excellent function, 2 had good function, and 1 had fair function. The excellent rate was 92.3%. At the final follow-up, the ipsilateral carrying angle ranged from 4° to 15° (mean angle, 11°).Computer simulation based on 3D-CT reconstruction can provide good information on the right humeral osteotomy position and osteotomy angle. It can guide the actual operation and provide better results after surgery. Intraoperative elbow arthrography is useful to determine the level of elbow joint osteotomy, and it can assist in the operation.Level of evidence: Level IV-retrospective case, treatment study.

[Corrective osteotomies for posttraumatic elbow deformities]

OBJECTIVES

Correcion of elbow joint deformities that usually develop secondary to direct or indirect trauma of the arm or elbow with subsequent inadequate healing and consecutive axial/rotational malalignment and may be associated with cosmetic or functional deficits of the arm.

INDICATIONS

Relevant malalignment of the arm axis with corresponding cosmetic or functional deficits for the patient.

CONTRAINDICATIONS

Pre-existing degenerative and chronic inflammatory changes.

SURGICAL TECHNIQUE

Generally, two-dimensional supracondylar open or closed wedge osteotomies are used. In the presence of a three-dimensional deformity (with rotational component), an additional derotational correction is necessary. Extra-articular deformities following extension fractures should be treated preferably with an open wedge osteotomy, extra-articular deformities of flexion fractures with a closed wedge osteotomy. Valgus/varus deformities may also require a closed/open wedge osteotomy primarily through a dorsal or alternatively radial approach.

POSTOPERATIVE MANAGEMENT

The arm should be immobilized with a brachial cast splint for 2-3 weeks, with passive exercises of the elbow starting on postoperative day 7.

RESULTS

In general, the results for a three-dimensional osteotomy of the distal humerus are expected to be good to very good. Only in rare cases (2.5%) is a mostly transient irritation of the ulnar nerve observed.