Double dome osteotomy for the treatment of cubitus varus in children

Shortening dome osteotomy for correction of severe cubitus varus secondary to malunited supracondylar fractures in children

The results of conventional corrective procedures remain suboptimal for severe cubitus varus deformities (> 30^°) in children. We present the results of shortening dome osteotomy for the correction of such deformities.

PATIENTS AND METHODS

We present retrospective review of prospectively collected data of 18 patients (11 boys and 7 girls) who underwent shortening dome osteotomy between January 2011 and December 2019 for severe cubitus varus deformities (> 30^°) secondary to malunited supracondylar fracture. The procedure involved the removal of convexo-concave bone (5-8 mm wide) between the two domes. Humero-ulnar angles, lateral condylar prominence index (LCPI), and elbow range of movements were recorded preoperatively and postoperatively.

RESULTS

Mean age was 7.5 years (range 5 years-11 years). Indication for surgery was poor cosmesis in all the patients and tardy ulnar nerve symptoms in three patients. Mean preoperative humero-ulnar angle was 26.1^° varus (range 22^°-34^°), while it was 7.1^° valgus (range 0^°-12^°) for contralateral normal elbow. They were followed for a mean duration of 2.2 years (range 12 months-5.8 years). The mean postoperative valgus angle achieved was 7.3^° (range 2^°-12^°) as total angular correction achieved was 34.4^° (range 30^°-44^°) (p < 0.001). Radiological healing was observed in all the patients at mean duration of 7.1 weeks (range 5 weeks-9 weeks). Mean preoperative and postoperative LCPI were - 2.4 (range +4.7 to - 10.5) and - 1.7 (range +4.5 to - 5.1), respectively (p = 0.595). Three patients had pin tract infections and two of them responded to aseptic dressings and oral antibiotics, while another required early pin removal and additional protection in splint. All patients regained preoperative arc of motion within 6 months after the procedure.

CONCLUSION

Shortening dome osteotomy is a safe and effective method for correcting severe cubitus varus deformities (> 30^°) secondary to malunited supracondylar fracture in children.

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.

Trapezoidal Osteotomy for Treatment of Long-Standing Nonunion of Lateral Humeral Condyle Fracture With Cubitus Valgus Deformity

PURPOSE

Long-term nonunion of the lateral humerus condyle fracture may lead to progressive cubitus valgus, elbow pain and instability, and secondary ulnar neuritis. A number of techniques of osteotomy are available for correction, but each has its disadvantages. The aim of this study was to present a technique of medial trapezoidal osteotomy for correcting nonunion of the lateral humeral condyle with an elbow valgus deformity >20°.

METHODS

Eight patients (mean age, 7.5 years) with cubitus valgus, after neglected nonunion of a lateral humeral condyle fracture of greater than 2 years duration, were treated with trapezoidal combined osteotomy. The mean interval from the lateral condylar fracture to surgery was 3.1 years. The osteotomy lines were marked on the bone with a template made before surgery. The lateral condyle and osteotomy site were fixed with K-wires, and the elbow joint was immobilized in a plaster brace. Pre- and postoperative carrying angles, range of motion, elbow function, and ulnar nerve neuropathy were analyzed.

RESULTS

The mean follow-up was 5.9 years. Union of the lateral condyle was achieved in all patients; 3 healed at 8 weeks, 2 healed at 9 weeks, 2 healed at 10 weeks, and 1 healed at 12 weeks. The mean carrying angle decreased from 30.1° before surgery to 5.8° after surgery. The surgery did not reduce the range of motion at the elbow. According to the Mayo Elbow Performance Score, 6 patients had excellent elbow function, and 2 had good elbow function at the last follow-up. All preoperative ulnar nerve symptoms resolved. One patient had a mild surgical site infection. No other complications occurred.

CONCLUSIONS

Medial trapezoidal osteotomy appears to be an effective method for treating nonunion of lateral humeral epicondyle fracture with cubitus valgus deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

Shortening Dome Osteotomy for Correction of Complex Multiplanar Elbow Deformities: A New Surgical Technique

Despite surgical advances in fracture management, it is not uncommon to find pediatric or adolescent patients with elbow deformities. Correction of severe deformities, often leaves the ingenuity of the treating surgeon asking for more. Various osteotomy techniques have been described in the literature for the correction of elbow deformities. Although, the concept of dome osteotomy did address certain inadequacies of the existing osteotomy techniques for distal humerus, but correction of complex deformities associated with deformation of trochlea and olecranon fossa still remain a surgical challenge which has not been adequately addressed in the literature so far. Our experience with the existing osteotomies for distal humerus led to the development of a new surgical technique of shortening dome osteotomy for correction of such complex multiplanar elbow deformities. Surgical steps, indications, and expected outcome is described.

Results of the modified reverse step-cut osteotomy in paediatric cubitus varus

PURPOSE

Cubitus varus deformity occurs in children as a late consequence of supracondylar fracture of the distal humerus. Different types of corrective osteotomies have been described, but a gold standard has not yet been established. The aim of this study is to report the clinical, radiological, and cosmetic outcome of the modified reverse step-cut osteotomy technique.

METHODS

This study was conducted on 15 cases, which were operated during the period between July 2015 and June 2016. We used the technique modified reverse step-cut osteotomy with the calculated medial translation of the distal fragment to correct varus and sagittal plane deformity and to achieve anatomical alignment of the forearm axis with the axis of the humerus. Follow-up was done for two years. Pre-operative and post-operative clinical and radiological parameters were compared, and patient satisfaction was assessed.

RESULTS

The mean pre-operative humerus-elbow-wrist (HEW) angle was - 22.4°; it improved to + 9.4° post-operatively. The pre-operative mean range of motion was 131.6°, and the post-operative mean was 132°. The clinico-radiological outcome was assessed according to Oppenheim criteria. There was an excellent result in nine patients (60%), a good result in five patients (33.3%), and poor results in one patient (6.6%). Cosmetic outcome was assessed as per Barrett's criteria, excellent result in thirteen patients (86.6%) and poor results in two patients (13.3%). Post-operative lateral condylar prominence index (LCPI) was compared with the normal side, and there was no significant difference.

CONCLUSION

We have achieved satisfactory results with acceptable cosmetic appearance and functional outcomes with minimal complications. We recommend this technique as a safe, reliable, reproducible, technically easy procedure for correction of cubitus varus deformity.

Triple management of cubitus valgus deformity complicating neglected nonunion of fractures of lateral humeral condyle in children: a case series

BACKGROUND

Long standing nonunion of the lateral humeral condyle (LHC) usually results in elbow pain and instability with progressive cubitus valgus and tardy ulnar neuritis. Surgical treatment of long standing nonunion is still a controversial issue due to the reported complications, such as stiffness, loss of elbow motion, and avascular necrosis of the LHC fragment. In this study, we reported the outcomes of treatment of cubitus valgus deformity in long standing nonunion of the LHC in children treated with combined triple management (fixation of the nonunion site, dome corrective osteotomy, and anterior transposition of ulnar nerve) through a modified para-triceptal approach.

METHODS

We evaluated ten patients with cubitus valgus deformity more than 20 degrees after neglected nonunion of the lateral humeral condyle more than 24 months. Only childern with post-operative follow up more than 24 months were included in this study. All patients were evaluated clinically, radio logically, and by pre- and post-operative functional evaluation using Mayo elbow performance score. For evaluation of ulnar nerve affection, the Akahori's system was used.

RESULTS

There were six females and four males with the average age of 7.7 years at operation. The left elbow was affected in six patients and the right elbow was affected in four patients. The average time between fracture of the LHC and operation was 40.3 months with average post-operative follow up of 44.3 months. The average carrying angle of the healthy side was 5.5 degrees and pre-operative carrying angle of the affected side was 33.5 degrees. The average post-operative carrying angle of the affected side was 6.1 degrees. The improvement of the carrying angle at the last follow up was found statistically significant (p < 0.05). All six patients that had pre-operative various degrees of ulnar nerve affection had completely improved at last follow up. The osteotomy site united in an average time of 43 days, whereas the LHC nonunion site united in an average time of 77.2 days. The osteotomy site united in significantly less time than the LHC non-union site (p < 0.05). The correlation between time since injury and time of union of LHC non-union site was significant (p < 0.05). Post-operative elbow range of motion was not changed in five patients, slightly decreased in four patients, and increased in one patient. Three patients had an average 6.7 degrees (range; 5-10) loss of the last degrees of flexion. One patient developed extension lag of 10 degrees. The mean elbow range of motion (ROM) pre-operatively was 139 ± 4.6 degrees while the mean post-operative ROM was 138 ± 5.3 degrees. The difference was found to be statistically insignificant (p > 0.05). The mean pre-operative Mayo elbow performance score was poor 55 ± 9.7, four patients had fair score, and six had poor score. The mean post-operative Mayo elbow performance score was excellent 92.5 ± 10, six patients had excellent score, and four had good score. The improvement of the Mayo score at the last follow up was found to be statistically significant (p < 0.05). No intra-operative complications were recorded during any of the procedures and no patient developed a wound or pin track infection post-operatively. At the last follow up, none of the patients had developed avascular necrosis of the LHC.

CONCLUSION

Preservation of the blood supply of the nonunited fragment is the key to successful management. This combined technique successfully addresses different aspects of the problem simultaneously and provides a durable solution without deterioration of the results over time. The para-triceptal approach provided excellent exposure of both sides of the elbow with minimal disruption of the triceps muscle.

Lateral closing isosceles triangular osteotomy for the treatment of a post-traumatic cubitus varus deformity in children

AIMS

Cubitus varus is the most common late complication of a supracondylar fracture of the humerus in children. Correction can be performed using one of a number of techniques of osteotomy but each has disadvantages. We describe a new technique for correcting post-traumatic cubitus varus using a lateral closing wedge isosceles triangular osteotomy.

PATIENTS AND METHODS

A lateral closing wedge isosceles triangular osteotomy was performed in 25 patients (15 male and ten female with a mean age of 9.5 years (6 to 12)) between May 2010 and April 2013. All patients had cubitus varus secondary to malunion of a supracondylar fracture, with good function of the elbow and a full range of movement. The osteotomy lines were marked on the bone with an isosceles triangular template made before surgery, after which the osteotomy was performed leaving the medial cortex intact. Fixation was performed using two lateral 2 mm Kirschner (K)-wires and patients were immobilised in an above-elbow plaster. By six to eight weeks callus was present and the wires and cast were removed. Patients were reviewed at four and six weeks, three, six and 12 months and then every two years until skeletal maturity. Clinical and radiographic outcomes were categorised as excellent, good or poor.

RESULTS

A total of 23 patients had an excellent and two had a good outcome at a mean final follow-up of 3.4 years (two to four). The mean post-operative carrying angle in the corrected elbow was 11.7° (7° to 18°). One patient fell, displacing the osteotomy, and needed revision of the fixation. No patient had a nerve injury.

CONCLUSION

A lateral isosceles triangular osteotomy and with K-wire fixation is a practical, effective, reliable, safe and simple method of correcting post-traumatic cubitus varus in children. It has inherent stability and excellent cosmesis without prominence of the lateral condyle. Cite this article: Bone Joint J 2016;98-B:1521-5.

Modified step-cut osteotomy for correction of post-traumatic cubitus varus deformity: a report of 19 cases

We reviewed the outcomes of post-traumatic varus deformity treated with modified step-cut osteotomy in 19 patients (average age, 7.4 years; range, 4.3-16.8 years at time of surgery). The average follow-up period was 29.6 months. The mean range of motion was 15.0°/124.7° (extension/flexion) before surgery and 6.8°/132.6° at final follow-up. The humerus-elbow-wrist angle was -21.1° before surgery and 4.2° at final follow-up, with a loss of 4.4° from the value of the humerus-elbow-wrist angle after the surgery. Osteotomy was fixed with Kirschner wires, and, in five cases, chips of excised bone could be inserted to avoid elbow extension. However, in eight cases, usually concerning younger patients, the elbow was fixed in hyperextension higher than 5°. No patient developed postoperative infections or later complications. Only one patient had transient nerve palsy. The modified step-cut osteotomy can precisely and stably correct the varus deformity in the coronal plane, especially in patients under 10 years of age. To avoid radial nerve palsy, we recommend that the retractors be removed sometimes during the operation.

Surgical Correction of Cubitus Varus

Cubitus varus can arise from distal humerus fractures in childhood as a result of malunion, nonunion, or overgrowth. Several types of distal humerus osteotomies have been described to treat this deformity, each with its own benefits, drawbacks, and complications. This article details the surgical technique and expected outcomes for 4 of the most commonly used types of distal humerus osteotomies in the treatment of cubitus varus. Specifically, we will describe the techniques for the lateral closing-wedge osteotomy, the step-cut osteotomy and its variations, the dome osteotomy and its variations, and the multiplanar osteotomy.