Lateral closed wedge osteotomy for cubitus varus deformity

Background:

Lateral closed wedge (LCW) osteotomy is a commonly accepted method for the correction of the cubitus varus deformity. The fixation of osteotomy is required to prevent loss of correction achieved. The fixation of the osteotomy by the two screw and figure of eight wire is not stable enough to maintain the correction achieved during surgery. In this prospective study we supplemented the fixation by Kirschner''s (K-) wires for stable fixation and evaluated the results.

Materials and Methods:

Twenty-one cases of the cubitus varus deformity following supracondylar fractures of the humerus were operated by LCW osteotomy during February 2001 to June 2006. The mean age of the patients at the time of corrective surgery was 8.5 years (range 6.6-14 years). The osteotomy was fixed by two screws with figure of eight tension band wire between them and the fixation was supplemented by passing two to three K-wires from the lateral condyle engaging the proximal medial cortex through the osteotomy site.

Result:

The mean follow-up period was 2.5 years (range seven months to 3.4 years). The results were assessed as per Morrey criteria. Eighteen cases showed excellent results and three cases showed good results. Two cases had superficial pin tract infection.

Conclusion:

The additional fixation by K wires controls rotational forces effectively besides angulation and translation forces and maintains the correction achieved peroperatively.     

Correction of cubitus varus by French or dome osteotomy: a comparative study

BACKGROUND: The purpose of this study was to compare the outcomes of two different techniques of supracondylar osteotomy, French osteotomy and dome osteotomy, for the correction of posttraumatic cubitus varus. METHODS: A comparative randomized study was undertaken of 25 patients (average age 10 years) with an established posttraumatic cubitus varus deformity (mean time from injury to corrective osteotomy, 1.7 years). Patients were followed-up with for 1 year, and carrying angle, Baumann's angle, and internal rotation deformity were measured. Postoperative complications were assessed. RESULTS: A significant (p < 0.01) correction of carrying angle and Baumann's angle was achieved with both techniques, with no statistically significant differences between them. Although internal rotation deformity was corrected by both techniques, the correction was significantly greater with the dome osteotomy (p < 0.01). However, the persistence of internal rotation did not seem to affect the final outcome. There was a higher incidence of postoperative complications in the dome osteotomy group, including infection (1), inadequate correction (1), nerve palsy (1), loss of motion (5), and circulatory compromise (1). CONCLUSION: The dome osteotomy is technically more difficult than the French osteotomy and has a higher incidence of complications. We suggest that the French osteotomy be used for the correction of cubitus varus after supracondylar fractures of the elbow in children.     

Dome corrective osteotomy for cubitus varus deformity

Between 1994 and 1998, 15 patients had corrective dome-shaped osteotomy of the humerus for posttraumatic cubitus varus deformity. Thirteen patients had surgery before puberty and two patients had surgery after puberty. In the prepuberty group, all the osteotomies were done by a posterior approach with triceps muscle splitting, and cross pins were used to fix the osteotomy. In the postpuberty group, the osteotomies were done by a posterior approach with olecranon osteotomy, and reconstructive plates were used for fixation. The average followup was 2 years and 4 months. Preoperative carrying angle ranged from 19 degrees to 31 degrees varus (average, 26.2 degrees) and postoperative carrying angle ranged from 7 degrees to 15 degrees valgus (average, 10.7 degrees). No loss of correction was observed and all osteotomies united. The preoperative and postoperative differences of the lateral condylar prominence index ranged from -67% to +6% (average, -30.1%). After reviewing these cases, a dome-shaped osteotomy was found to have the following advantages for correction of cubitus varus deformity: the osteotomy site is more stable than a lateral closing wedge osteotomy for maintaining the correction obtained; the domed osteotomy avoids having the lateral condyle becoming prominent; and the posterior scar is more cosmetically acceptable than the lateral scar in the lateral closing wedge osteotomy.     

成人创伤后肘内翻畸形的矫形及双柱固定

目的探讨肱骨髁上截骨双钢板固定治疗成人创伤后肘内翻的方法及疗效。方法回顾性分析2007年6月-2010年12月手术治疗22例成人创伤后肘内翻畸形患者的临床资料。其中男16例,女6例;年龄18～29岁,平均21岁。既往均有肱骨髁上骨折病史;初次骨折后3个月～1年,平均6个月出现肘内翻畸形;出现畸形后4～17年,平均8年入院手术。术前患侧肘关节提携角为肘内翻16～25°,平均20.6°。肘关节功能采用Flynn评分均为差。术中行肱骨外侧闭合楔形截骨,以2块重建钢板塑形后分别置于肱骨内外侧柱以固定截骨断端。术后无需外固定,早期行功能锻炼。结果术后切口均Ⅰ期愈合。22例均获随访,随访时间6～24个月,平均13个月。末次随访时患侧肘关节提携角为肘外翻0～10°,平均7.5°。患者截骨处均骨性愈合,愈合时间8～13周,平均10周。术后无感染,神经、血管损伤,内固定物松动、断裂等并发症发生,无肘内翻复发。末次随访时Flynn评分优17例,良3例,中2例,优良率91%。结论采用肱骨髁上截骨加双钢板固定治疗成人创伤后肘内翻畸形,固定坚强,骨折愈合率高,术后能早期功能锻炼,肘关节功能恢复满意。     

Functional outcome of modified French osteotomy fixed with recon-locking compression plate in older children

IntroductionModified French osteotomy is commonly used method for the correction of cubitus varus deformity. Fixation of the osteotomy with figure of 8 wiring or 3.5 mm cortical screws were found to be insufficient in holding the distal fragment in children above 8 years. In this study we used a Reconstruction locking plate for the fixation of osteotomy in those children and evaluated the results.Materials and methodsModified French osteotomy and fixation with reconstruction locking compression plate was performed for eighteen cases of cubitus varus deformity within the time period of 5 years starting from March 2014 to February 2019.ResultsThe outcome of the study was assessed with Flynn’s criteria, where 12 cases had excellent and 6 cases had good outcome. There were no complications and no revision surgeries were performed.ConclusionReconstruction locking plate fixation of a modified French osteotomy in older children (above 8 years) provided excellent results in our study.     

A new three-dimensional osteotomy for cubitus varus deformity after supracondylar fracture of the humerus in children

In the past, supracondylar osteotomy for the correction of cubitus varus deformity has been associated with a high failure rate and significant complications, even in simple lateral closing wedge osteotomy. This is because the supracondylar area is thin and fixation is difficult to maintain. In cubitus varus deformity, not only medial, but posterior, tilt and internal rotation of the distal fragment also frequently occurs. To correct all these deformities and to achieve a wide bony contact and more rigid fixation than simple lateral closing wedge osteotomy, we propose a new three-dimensional osteotomy. Among 12 patients who received this osteotomy, 11 had an excellent result and one had a good result.     

Supracondylar osteotomy of the humerus for correction of cubitus varus

Reports of corrective procedures for cubitus varus (gunstock deformity) have emphasized the frequency of loss of position and significant complication. Modifications that have been made to the standard supracondylar osteotomy protocol include correction of the angular deformity only, without correction of rotation; an incomplete wedge osteotomy leaving the medial cortex intact by hinging the osteotomy shut on the intact cortex; and immobilization of the elbow in full extension with the forearm supinated. In a review of 16 patients following this protocol, 11 patients had excellent results, three had good results, and two had unsatisfactory results.     

外侧闭合楔形截骨术矫正儿童创伤性肘内翻畸形

目的探讨采用外侧闭合楔形截骨术矫正儿童创伤性肘内翻畸形的疗效。方法 1996年7月-2010年6月,收治儿童肱骨髁上骨折后肘内翻畸形20例。男13例,女7例。年龄7～14岁,平均10.6岁。左侧12例,右侧8例。13例曾于外院行闭合复位经皮克氏针内固定、石膏外固定,7例误诊为关节脱位和软组织损伤行石膏外固定。伤后2～12年出现肘关节外观异常和活动受限。术前肘关节活动范围为屈100～150°,平均133.0°;伸0～24°,平均11.7°。肘内翻角度为20～50°,平均32.1°。均采用外侧闭合楔形截骨术治疗。结果术后切口均Ⅰ期愈合,无相关并发症发生。17例患儿获随访,随访时间1～14年,平均5年。X线片示截骨区均达骨性愈合,愈合时间为5～8周,平均6周。肘关节内翻畸形均获矫正,末次随访时肘关节活动范围为屈110～150°,平均135.9°;伸0～27°,平均12.9°。根据Jupiter等肘关节评分系统评价肘关节功能,优14例,良2例,可1例,优良率94.1%。1例术后1个月拔除克氏针后畸形复发,1年后再次行外侧闭合楔形截骨术矫正。结论外侧闭合楔形截骨术具有操作简便、手术并发症少等优点,是治疗儿童创伤性肘内翻畸形有效方法之一。     

肱骨髁上楔形截骨联合改良张力带钢丝治疗肘内翻

目的探讨应用肱骨髁上楔形截骨矫形联合改良张力带钢丝内固定治疗肘内翻畸形的可行性与临床疗效。 方法选取自贡市第一人民医院2015年1月至2019年1月共37例肘内翻畸形患者,男21例,女16例;平均年龄(12.9±2.1)岁;有10例合并内旋畸形。采用肱骨髁上楔形截骨联合改良张力带钢丝进行治疗。采用配对设计资料t检验比较患侧肘关节术前及术后的内翻角、屈曲活动及伸直活动度;采用成组设计资料t检验比较患侧及健侧肘关节的提携角、屈曲活动及伸直活动度。 结果所有患者均得到随访,平均(2.0±0.8)年;截骨均全部愈合,完全愈合时间平均(74±10)d。术后患侧肘关节内翻畸形均明显矫正(t＝19.749,P<0.05);患侧肘关节屈曲活动、伸直活动度与术前比较改善(t＝3.279、-10.573,均为P<0.05);术后患侧肘关节提携角、屈曲活动及伸直活动度与健侧比较无差异(均为P>0.05)。所有患者术后切口均一期愈合,无感染、神经损伤发生,无内固定松动、脱落及断裂等并发症发生。 结论肱骨髁上楔形截骨矫形联合改良张力带钢丝内固定治疗肘内翻畸形,具有术中操作简便,内翻畸形矫正明显,内固定强度可靠,可早期功能锻炼,术后肘关节功能恢复好等优点。     

Supracondylar medial open wedge osteotomy with external fixation for cubitus varus deformity

BACKGROUND: Many surgical procedures are used for the correction of cubitus varus deformity in children. Even if the primary indication is cosmetic, but many poor results have been described. The technique of a supracondylar medial opening wedge osteotomy with external fixation is presented and preliminary results in four cases are reported. TECHNIQUE: An antero-medial approach is chosen with exposition and anterior transposition of the ulnar nerve. Under image intensifier control, insertion of four Schanz screws is performed from medial to lateral. In between, an incomplete medial osteotomy is performed obliquely (in the antero-posterior as well as in the medio-lateral plane), leaving a small part of the radial humeral cortex intact. The osteotomy is opened until varus and, if present, hyperextension deformation are corrected. Then, the fixator system is applied. RESULTS: All osteotomies healed primarily. Mean valgus correction of 21.75 degrees was achieved; in only one patient additional flexion modification of 17 degrees was necessary. At a follow-up of at least 2 years clinically three out of four presented symmetric elbow position, one slight residual varus deformity was noted in spite of 20 degrees of valgization due to important valgus position of the contralateral side. No lateral bulging of the corrected elbow was observed. CONCLUSION: The described technique is an alternative to other procedures, with special regard to the cosmetic outcome as well as to the control of correction for valgus and flexion.     

外侧闭合楔形截骨并交叉穿针皮外张力带固定治疗儿童肘内翻畸形

目的:探讨外侧闭合楔形截骨并交叉穿针外张力带固定治疗儿童肘内翻畸形的疗效。方法:2011年3月至2015年6月手术治疗肘内翻畸形儿童26例,其中男15例,女11例;年龄4~13岁,平均7.8岁;术前内翻角度11°~24°,平均(17.50±6.73)°,其中3例较健侧屈曲受限角度10°。均采用肘外侧切口,行肱骨远端髁上外侧闭合楔形截骨,保留内侧3~4 mm宽度的连续皮质,截骨对合后采用交叉克氏针穿针并皮外张力带(交叉针皮外部分在外侧反向折弯并针尾再返折相互钩绕)固定,截骨端外侧形成加压,术后随访比较治疗前后和健侧提携角,采用Laupattarakasem标准评价疗效。结果:26例均于术后2个月内骨性愈合,无感染和神经麻痹等并发症,随访时间13~29个月,平均18.8个月,提携角恢复为8°~14°,平均(11.50±3.17)°。Laupattarakasem标准评定术后优14例,良11例,可1例。结论:采用外侧闭合楔形截骨可以有效恢复肘内翻畸形,交叉穿针并皮外张力带固定可以满足术后早期活动要求。     

Ilizarov Gradual Distraction Correction for Distal Tibial Severe Varus Deformity Resulting from Epiphyseal Fracture: Case Report and Literature Review

We present a case of a 13-year-old female with severe varus deformity and limb discrepancy resulting from epiphyseal fracture. The preoperative tibial articular surface angle was 64.1°, and the affected tibia was 14 mm shorter than the contralateral tibia. She underwent a medial open osteotomy and fibular osteotomy with gradual distraction correction using Ilizarov fixator. The deformity was corrected at 3 months, and the external fixator was removed when bony union was achieved 6 months postoperatively. At 9 months after surgery, the patient could play basketball without feeling pain. At the last follow-up, namely 36 months after the operation, the American Orthopaedic Foot and Ankle Society hindfoot-ankle score was improved from 58 to 90, the patient was pain free, and the radiological measurements were nearly normal. Ilizarov fixator gradual distraction correction for distal tibial severe varus deformity is a safe and cost-effective method that can yield excellent radiological and clinical outcomes.     

Treatment of cubitus varus with osteotomy and Ilizarov external fixation

A cubitus varus deformity, secondary to a supracondylar fracture, was treated with a short oblique osteotomy and the Ilizarov external fixator. An excellent anatomic and functional outcome resulted. This method may prove to be of significant value in the treatment of this difficult deformity.     

小切口后外侧入路外侧闭合楔形截骨锁定钢板治疗成人肘内翻畸形

目的探讨小切口后外侧入路外侧闭合楔形截骨锁定钢板治疗成人肘内翻畸形的疗效。方法回顾性分析2013年7月至2017年9月期间武汉市第四医院手外一科收治的19例成人肘内翻畸形患者资料。男3例,女16例;年龄17~27岁,平均20.3岁;左侧13例,右侧6例;肘内翻角为20.7°±2.8°。所有患者术前在医学影像存档和传输系统(PACS)上精确测量健侧提携角及患侧的内翻角,并测算出截骨角度,术中采用小切口后外侧入路,外侧闭合楔形截骨矫形锁定钢板固定。末次随访时测量患肘提携角并采用Mayo肘关节功能评分标准(MEPS)评定肘关节功能,采用Bellemore方法评定肘矫形手术疗效。结果19例患者术后获9~32个月(平均14个月)随访,所有患者截骨处均愈合良好。末次随访时患肘提携角为11.4°±1.6°,患者手术瘢痕平均4 cm(3~5 cm),术后患肢肘内翻畸形与术前对比明显改善,肘关节功能良好。术后采用MEPS评定肘关节功能:优10例,良7例,中2例;采用Bellemore方法评定肘矫形手术疗效:优13例,良6例。2例患者术后出现尺神经部分损伤,1例患者术后出现轻度肘关节僵硬。所有患者随访期间未出现内固定物松动、断裂等失效情况,无一例出现骨折延迟愈合及不愈合。结论术前应用PACS系统精确测量截骨角度,术中应用小切口后外侧入路进行外侧闭合楔形截骨矫形,既确保了矫形角度和术后肘关节功能恢复,又未留下明显手术瘢痕,外形美观,疗效良好。     

肱骨髁上成角旋转中心微创截骨外固定治疗青少年肘内翻畸形

目的 :探讨采用肱骨髁上成角旋转中心(center of roration of angulation,CORA)微创截骨外固定治疗青少年肘内翻畸形的临床疗效。方法:自2013年8月至2017年8月,采用CORA微创截骨外固定治疗肱骨髁上骨折导致的青少年肘内翻畸形患者15例,其中男9例,女6例;年龄13～16岁,平均14.5岁;左侧11例,右侧4例;受伤至手术时间6～10年,平均7.5年,其中5例有肘内翻手术史术后复发。观察患者的矫正时间、骨折愈合时间及提携角,并采用Laupattarakasem标准进行疗效评价。结果:15例患者获得随访,时间12～30个月,平均24个月;畸形矫正时间3～5周,平均4周;骨愈合时间4～6个月,平均5个月;提携角由术前的-12°～-23°提高至术后的9°～14°。根据Laupattarakasem标准,本组优11例,良3例,可1例。结论:采用肱骨髁上CORA微创截骨外固定治疗青少年肘内翻畸形,具有微创、出血少、术后早期功能锻炼,矫形速度、角度可控,无须住院取除外固定等优点。     

The correction of post-traumatic cubitus varus by hemi-wedge osteotomy

Summary Osteotomy was performed for cubitus varus deformity in 14 patients following supracondylar fracture of the humerus. In the first four patients the osteotomy was performed by a standard wedge technique and in the last ten cases by a new technique of hemiwedge osteotomy. The hemi-wedge technique permitted better control of the correction and better fixation of the osteotomy. Before the operation all cases had a cubitus varus of 10° or more. After the operation all but one patient had a normal carrying angle or at most a cubitus varus of 5°. In this case the standard osteotomy failed because of poor fixation and after re-operation by the hemi-wedge osteotomy because of infection.

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Résumé Chez 14 malades, une déformation en cubitus varus, après fracture supracondylienne de l'humérus, a été traitée par ostéotomie. Dans les quatre premiers cas, les auteurs ont réalisé une ostéotomie cunéiforme standard et dans les dix derniers cas, ils ont eu recours à une nouvelle technique d'ostéotomie hémicunéiforme. Cette technique permet un meilleur contrôle de la correction et une meilleure fixation de l'ostéotomie. Avant l'opération, le cubitus varus était, dans tous les cas, de 10° ou davantage. Après l'opération, tous les malades sauf un avaient retrouvé un angle brachio-antibrachial normal, ou, tout au plus, un cubitus varus de 5°. Dans ce cas, l'ostéotomie standard avait échoué en raison d'une fixation insuffisante, ainsi que la réintervention par ostéotomie hémicunéiforme à cause d'une infection postopératoire.

     

A new osteotomy for cubitus varus

From 1974 to 1986, a step-cut technique of distal humerus valgus osteotomy using one cortical screw for fixation was used to correct cubitus varus deformity in 11 patients. The results were graded as excellent, eight patients, good, two, and poor, one. The poor result was secondary to persistent varus. The average humeral-elbow-wrist angle in the ten patients with valgus correction roentgenographically measured 9.3 degrees. The average amount of correction was 28.4 degrees. All patients retained their preoperative level of elbow motion. There were no radial or ulnar nerve injuries, nonunions, infections, or hypertrophic scars. The osteotomy requires careful preoperative planning and special attention to surgical detail. Large amounts of deformity may be corrected safely with a low complication rate.     

Supracondylar humeral osteotomy in children with severe posttraumatic cubitus varus deformity

The authors report the results of corrective osteotomy of the humerus in 11 children with severe posttraumatic cubitus varus deformity. The average carrying angle on the affected side was -24.4 degrees, and there was an average internal rotation deformity of the distal humerus of 22 degrees. Flexion and extension of the injured elbow were severely limited. A supracondylar lateral wedge osteotomy of the humerus was performed keeping the medial cortex intact. Two K-wires served as levers to correct the angular and rotational deformity of the elbow and then as fixation material to hold the osteotomy fragments. Postoperatively we immobilized the elbows in 90 degrees flexion for 3 to 4 weeks. There was no loss of the postoperative osteotomy alignment in most cases. Recurrence of mild varus deformity (-5 degrees and -7 degrees) occurred in only two patients. At the end of the follow-up we observed excellent results in 9 patients with an average carrying angle of 7.2 degrees (range 5-10 degrees).     

Prospective study of the anterior cruciate ligament reconstruction associated with high tibial opening wedge osteotomy in knee arthritis associated with instability

IntroductionChronic ACL insufficiency with associated varus malalignment due to knee osteoarthritis (OA) is challenging to treat surgically. A combined ACL reconstruction (ACLR) with medial open wedge high tibial osteotomy (HTO) without using any metallic implant for HTO is an effective technique.Materials and methodAll the patients attending the outpatient department ACL injury and with associated medial compartment OA (Kellegren's grade 2 and grade 3) were considered for inclusion in the study. Forty patients who met inclusion criteria were included in the study. Simultaneous ACLR (single bundle of quadrupled hamstring graft fixed with Endobutton on femoral side and biointerference screw on the tibial side) along with medial opening wedge osteotomy (with tricalcium phosphate wedge) was done. The patients were assessed with IKDC, KOOS scores and any change in anterior tibial translation was also checked.ResultsThe combined procedure showed mean varus angle correction of 9° (10.5–1.5°), and the mechanical axis of the knee was restored from an average of 172–181.5°. There was a significant improvement in knee score (KOOS and IKDC) after the surgery (p < 0.05). The average time for the radiological union of the osteotomy was 3.56 months. The anterior tibial translation was improved. No intraoperative complications and slippage of the synthetic graft were noted in any case.ConclusionsCombined ACLR with HTO (using TCP wedge, without any hardware) is a reliable method that prevents rapid progression of OA. It reliably corrects varus deformity and obviates the use of any hardware.