Lateral wedge osteotomy for pediatric post-traumatic cubitus varus: Kirschner-wires or locking angular plate?

Posttraumatic Cubitus Varus: Respect the Columns

Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.

Application of Kirschner wire placement guided technology in paediatric supracondylar humerus fractures

BACKGROUND

To analyze the clinical efficacy of K-wire placement guided technology in paediatric supracondylar humerus fractures.

METHODS

A retrospective study was conducted in 105 patients who underwent closed reduction and percutaneous pinning surgeries in our hospital from June 2019 to August 2022. 54 patients treated with a assisted reduction fixation device to assist in closed reduction and percutaneous K-wire cross-fixation were allocated into the Non-guided group, and 51 patients with K-wire placement guided technology to guide K-wire placement were assigned into the Guided group. The operation duration, number of disposable K-wire placement, intraoperative fluoroscopy frequency, Baumann angle, carrying angle, fracture healing time and Flynn score of elbow joint function at the final follow-up were compared between two groups. The postoperative complications of two groups were recorded.

RESULTS

There were significant differences between two groups in terms of operation duration, intraoperative fluoroscopy frequency, and disposable K-wire placement rate (p < 0. 05), while no significant differences of Baumann angle, carrying angle and the fracture healing time between two groups were observed (p > 0. 05). In the control group, ulnar nerve injury in 2 case, pin site infection in 4 cases, mild cubitus varus in 2 cases and loss of reduction in 4 cases were detected. In the study group, ulnar nerve injury in 1 case, pin site infection in 2 cases and loss of reduction in 1 case was observed. There was no significant difference in Flynn scores between two groups.

CONCLUSION

K-wire placement guided technology is simple and convenient. The application of K-wire placement guided technology could relatively improved disposable K-wire placement rate, shorten the intraoperative fluoroscopy frequencies and reduce complication rates.

Correction of Pediatric Cubitus Varus by Centralization of the Distal Humeral Fragment: A Surgical Technique to Avoid Lateral Condylar Prominence

BACKGROUND

Cubitus varus is a well-recognized late complication of supracondylar humerus fractures in children. Various osteotomies have been described to correct this deformity, but each has disadvantages. The purpose of this study was to investigate the outcomes of a surgical technique, lateral closing wedge osteotomy combined with centralization of the distal humeral fragment, in cubitus varus. Meanwhile, the occurrence of postoperative lateral condylar prominence was observed.

METHODS

From January 2015 to December 2019, 36 pediatric cubitus varus deformity patients who were treated with lateral closing wedge osteotomy combined with centralization of the distal fragment in our institution were included. The corrective osteotomies were performed through a standard lateral approach and fixed with crossed Kirschner wires. The preoperative and postoperative full-length anteroposterior and lateral radiographs of bilateral upper limbs were assessed. At the same time, clinical and radiologic parameters were reviewed. Lateral condylar prominence index (LCPI) and any other complications were evaluated.

RESULTS

The mean preoperative humerus-elbow-wrist angle (HEWA) on the affected side was 20.9 degrees of varus, which was significantly improved to 9.2 degrees of valgus postoperatively. The mean postoperative value of LCPI was -0.047. Postoperative LCPI and HEWA was compared with the normal side, and there was no significant difference. All of the patients had excellent clinical and radiographic alignment. No surgical complications and limitation of range of motion were noted. No patient complained of lateral bony prominence.

CONCLUSION

Lateral closing wedge osteotomy by centralization of distal fragment is a safe and highly effective method and prevents lateral prominence with a minimal complication rate. We recommend this technique for the treatment of cubitus varus in children.

LEVEL OF EVIDENCE

Level IV Case series.

A novel method of lateral closing wedge osteotomy for cubitus varus deformity in children

BACKGROUND

Humeral osteotomy is the best method for treatment of severe cubitus varus in children. Many osteotomy methods have been developed in the past. In this study, we describe a novel corrective technique by applying the principles described by Paley involving lateral osteotomy using Kirschner wires (K-wires). Vertices of the osteotomy should be located at the center of rotation of angulation. The anatomical and mechanical axes can be corrected with precision.

PATIENTS AND METHODS

In this retrospective study, 21 patients (17 male, 4 female) who fulfilled the study criteria and underwent lateral closing osteotomy for cubitus varus deformity from July 2015 to October 2017 were included into the study. The osteotomy line of all patients was designed according to Paley's principles. An isosceles triangle template was made according to the design preoperatively. The lateral osteotomy was made with the assistance of C-arm radiographs. The osteotomy was fixed by K-wires laterally. Patients were followed up, and elbows were evaluated by radiography and using the Mayo Elbow Performance Index (MEPI) score.

RESULTS

The mean correction angle obtained was 32.33°±2.83°. According to the MEPI score assessment, 19 of the 21 patients had an excellent outcome and two had a good outcome. Two patients complained of conspicuous scars; however, no further cosmetic surgery was performed. The range of motion was 135.0° preoperatively and 133.7° postoperatively, showing no significant difference (p = 0.326). None showed evidence of neurovascular injury or complained of prominence of the lateral humerus.

CONCLUSION

Paley's principles for correcting cubitus varus deformity in children are effective and reliable for treating such a condition.

LEVEL OF EVIDENCE

Therapeutic IV.

Effect of a functional brace in combination with physical therapy for early correction of cubitus varus in young children

Background

This study aimed to assess the clinical and radiologic outcomes of a functional brace in combination with physical therapy (FBPT) for early correction of cubitus varus in young children.

Methods

Eighteen consecutive patients with cubitus varus secondary to supracondylar fractures were enrolled between July 2017 and March 2019. We used the FBPT technique to correct varus and sagittal plane deformity for early cubitus varus in young children. The clinical evaluation included measurement of varus angulation, sagittal plane, and range of motion at three, six, and twelve months post-intervention. The clinical and radiographic results were assessed according to the Bellemore criteria.

Results

Pre-treatment humerus-elbow-wrist (HEW) angle measured on the affected side (varus deformity) ranged between -38° and -12° (average, -23.2°) while the post-treatment HEW angle ranged between -10° and + 15° (average, 8.8°). Compared with the unaffected side, no statistically significant difference was found in the affected side post-intervention (P > 0.05). According to the Bellemore criteria, we got excellent results in fourteen patients (77.8%), good results in three patients (16.7%), and poor result in one patient (5.5%). All patients and their parents (except one patient with residual varus deformities) were satisfied with the functional and cosmetic outcomes.

Conclusions

The FBPT is effective for the treatment of cubitus varus in children, especially for young children within 6 months of the injury.

Neural wedge osteotomy method of correction for cubitus varus deformity in children

In this study, we evaluated the clinical outcome of neutral wedge osteotomy assisted with the center of rotation of angulation (CORA) method of distal humerus anatomical axis for the treatment of cubitus varus deformity in children. From 2016 to 2019, 20 children with cubitus varus deformity after supracondylar fracture of the humerus were enrolled. Standard anteroposterior radiograph of the humerus was taken preoperatively. The CORA point and angulation angles were obtained by measuring the proximal and distal humerus anatomical axis. During the operation, neutral wedge osteotomy was performed to correct the varus deformity. The Baumann angle and the carrying angle were used to evaluate the correction effect of the distal humeral varus deformity. The average age of the patients was 7.8 years. Patients were followed up for an average of 29.3 months (range, 24-36 months). The average interval between surgery and injury was 12 months. The mean preoperative Baumann angle and carrying angle were 99° (90°-115°) and -14° (range, -10° to -30°), respectively. At the last follow-up, the mean Baumann angle and carrying angle was 76° (70°-80°) and 13.6° (10°-18°), respectively, with 16 cases showing excellent outcome and 4 cases showing good outcome. Our results indicated that the neutral wedge osteotomy assisted with CORA method of distal humerus anatomical axis showed good clinical outcomes in the treatment of cubitus varus deformity in children and is worthy of clinical application. The level of evidence is IV.

The lateral curved osteotomy for cubitus varus deformity in children: A case report and literature review

Introduction

Cubitus varus deformity after malunited supracondylar humerus fracture has various surgical techniques, implant configurations, and approaches. We describe a combination of French and Dome osteotomy and novel internal fixation technique to deliver an easy, safe, fast and reproducible result based on the current best evidence.

Presentation of case

Two cases of malunited supracondylar humerus are described. The first case involves a 3-year-old girl who presented with outstretched and supinated left arm after falling during bike riding 3 weeks earlier. We found no abnormality in radial and median nerve function, but the left arm radiographs showed a callus formation and the early stages of a malunited fracture of the supracondylar humerus. We waited two months for further radiographic evaluation and the radiographs showed the malunited supracondylar humerus with elbow flexion of only 105° and elbow hyperextension of 20°. The cubitus varus was recorded with clinical carrying angle of varus 10°. We used a combination of original French and Dome osteotomy, lateral approach, and our novel fixation technique with excellent results. The second case involved a 8-year-old boy with malunited right elbow and the surgery was done in the same manner, with the result of restoration to normal elbow range of motion. We also assessed the pain score and disabilities of the arm, shoulder and hand (DASH) score and recorded satisfactory results.

Conclusions

The combination of French and Dome osteotomy for treatment of cubitus varus deformity can provide an easy, safe, and reproducible result.

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Cubitus varus deformity.

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Malunited supracondylar humerus.

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French osteotomy.

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Dome osteotomy.

Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients

Background

We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures¹. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI)², lateral condylar fractures³, snapping medial triceps, and ulnar nerve instability⁴. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications.

Description

We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis.

Alternatives

Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition⁵. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut^6-9, dome, 3-dimensional¹⁰, or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially)^11,12. Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes¹³. Three-dimensional planning employs computed tomography to create expensive anatomic cutting guides that address varus, extension, and internal rotation. However, residual internal rotation is generally well tolerated, derotation is associated with loss of fixation, and the extension deformity will successfully remodel in patients who are <10 years old¹⁴. We employ 3-dimensional planning in skeletally mature patients with complex deformity and no remodeling potential.

Rationale

The oblique lateral closing wedge is ideal for skeletally immature patients because it is simple, reproducible, and efficient. It avoids the lateral prominence without increasing complexity or complications.

[Dual-planar osteotomy and lateral column anatomic locking plate fixation in the treatment of adult cubitus varus deformity]

Objective

To explore the effectiveness of distal humeral dual-planar osteotomy followed with distal humeral lateral column anotomical locking plate fixation in the treatment of adult cubitus varus deformity combined with flexion restriction.

Methods

The clinical data of 6 adult patients with cubitus varus deformity and flexion restriction treated with dual-planar osteotomy and internal fixation between April 2012 and September 2014 were reviewed. There were 3 males and 3 females with an average age of 22.2 years (range, 18-35 years). All the patients had history of elbow injury in childhood, the age being injured was 6.5 years on average (range, 2-13 years). There was no nerve injury, elbow strength weak, or unstable complications before admission. The preoperative elbow flexion was (107.50±5.24)°, elbow extension was (-12.17±3.48)°; the carring angle was (-19.50±4.46)°, the contralateral elbow carrying angle was (11.50±2.67)°; the length of humerus was (0.42±0.38) cm shorter than the unaffected humerus. The postoperative carrying angles, elbow flexion and extension, and humerus length were recorded. The modified Laupattarakasem criteria in which the comparison of bilateral elbow range of motion excluded was used to evaluate the results.

Results

Primary healing of incision was got in all patients and there was no early postoperative complications. All the patients were followed up 19-27 months (mean, 20.8 months). During the follow-up, there was no complication such as loosening and breakage of the internal fixators and all fractures were healed within 3 months after operation. At last follow-up, the elbow flexion was (124.17±5.85)°, the elbow extension was (0.83±2.04)°, the carrying angle was (12.00±4.19)°, and the humerus shortening was (1.88±0.45) cm, all showing significant difference when compared with preoperative ones ( t=-6.742, P=0.001; t=-11.068, P=0.000; t=-20.400, P=0.000; t=-13.914, P=0.000). According to the modified Laupattarakasem criteria, 1 case was excellent, 4 were good, and 1 was fair with an excellent and good rate of 83.3%.

Conclusion

Normal carrying angle can be restored and elbow flexion can be increased by coronal closing wedge and sagittal trapezoid dual-planar osteotomy, single lateral anatomical locking plate fixation is available for early mobilization.