|Year : 2017 | Volume
| Issue : 1 | Page : 12-15
Step-cut translation osteotomy and Y-plate fixation: A novel method for correction of cubitus varus and valgus deformity
Kumar Shashi Kant1, Vikas Gupta2
1 Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalya, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, India
2 Central Institute of Orthopaedics, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, India
|Date of Web Publication||17-Feb-2017|
Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Introduction: Many types of osteotomy have been proposed for the treatment of cubitus varus and valgus deformity. All these osteotomies have their advantages and disadvantages; however, till date there is no uniform consensus as to which osteotomy is the best suited for correction of these deformities. Materials and Methods: We reviewed the results of step-cut translation osteotomy in the management of cubitus varus and cubitus valgus deformity. This study includes 27 cases of cubitus varus and five cases of cubitus valgus deformity that underwent supracondylar step-cut translation osteotomy with Y-plate fixation for correction of the deformity. Results: The results were evaluated according to the modified criteria of Oppenheim et al. There were 25 excellent, six good, and one poor result. Overall, complication rate in our series was 12.5% (4/32). There was no recurrence of deformity in the available follow-up. Conclusions: Step-cut translation osteotomy is a relatively simple procedure that corrects cubitus varus and valgus deformities without any prominence of the medial or lateral condyle. Moreover, a wide osteotomy surface and rigid fixation allows early mobilization of the joint with good clinical results.
Keywords: Cubitus valgus, cubitus varus, step-cut osteotomy
|How to cite this article:|
Kant KS, Gupta V. Step-cut translation osteotomy and Y-plate fixation: A novel method for correction of cubitus varus and valgus deformity. Paediatr Orthop Relat Sci 2017;3:12-5
|How to cite this URL:|
Kant KS, Gupta V. Step-cut translation osteotomy and Y-plate fixation: A novel method for correction of cubitus varus and valgus deformity. Paediatr Orthop Relat Sci [serial online] 2017 [cited 2018 Mar 20];3:12-5. Available from: http://www.pors.co.in/text.asp?2017/3/1/12/200294
| Introduction|| |
Modern techniques of managing fractures around the elbow have significantly reduced the incidence of cubitus varus and valgus malunion. However, despite improvement in surgical techniques and availability of better operating facilities, malunions continue to occur. Cubitus varus deformity is the most common complication of supracondylar fractures of the humerus in childhood. This deformity requires surgical correction not only for cosmetic reasons but also to prevent functional consequences in the future, such as an increased risk of fractures of the lateral condyle.
On review of literature, the treatment of cubitus varus and valgus has evolved from a lateral closing wedge osteotomy, and medial opening wedge osteotomy to various modifications of these osteotomies. These include dome,, and step-cut osteotomies. All these osteotomies have their advantages and disadvantages; however, till date, a consensus as to which osteotomy is best suited for correction of these deformities is lacking. We retrospectively reviewed the results of step-cut translation osteotomy and Y-plate fixation in the management of cubitus varus or valgus deformities.
| Materials and Methods|| |
This study was done at the Central Institute of Orthopaedics, Vardhamann Mahavir Medical College and Safdarjang Hospital, New Delhi, from October 2009 to March 2011, after approval of the ethical board. This study included 27 cases of cubitus varus and five cases of cubitus valgus deformity that underwent supracondylar step-cut translation osteotomy with Y-plate fixation. The indication for surgery was deformity that was cosmetically unacceptable to either the child or the parents.
Clinical carrying angle and range of motion of the elbow joint was measured using a hand held goniometer and compared with the normal side. Completely extending the elbow and keeping both the humeral condyles at the same horizontal level ascertained presence of a flexion contracture of the elbow. The extent of rotational deformity was also measured by the method described by Yamamoto et al. Radiographic assessment included anteroposterior (AP) radiographs of both the elbows in complete extension and forearms in supination. Radiographic assessment of the humerus–elbow–wrist (HEW) angle was done by measuring the angle formed by intersection of the mid-humeral and mid-forearm bone axis. The lateral prominence index (LPI) for cubitus varus and medial prominence index (MPI) for cubitus valgus deformities were also measured on preoperative and postoperative radiographs. These indices were calculated as the difference between the measured medial and lateral widths of the distal part of the humerus from the longitudinal mid-humeral axis and were expressed as a percentage of the total width of the distal humerus.
The correction angle was determined by comparing the HEW angles of the normal and deformed elbows. Care was taken to ensure that the elbow was fully extended and the forearm supinated for such radiographs. After tracing the outline of the affected elbow from the AP radiograph on the butter paper, it was cut out with scissors. This traced butter paper was reversed and superimposed on the radiograph of the normal elbow. The osteotomy was planned approximately 0.5–1 cm superior to the olecranon fossa and perpendicular to the axis of the humeral shaft. The distal fragment was then rotated laterally and translated medially so that the angle formed by initial osteotomy cut and the lateral edge of the humerus could then be traced on the proximal fragment forming the triangular area to be resected. We then cut out this triangular overlapping the area that was equal to the amount of bone to be resected from the proximal humeral fragment.
The surgery was performed with the patient supine to check the carrying angle of both the elbows intraoperatively. A bolster was put behind the shoulder on operative side, the shoulder was flexed to 900 and internally rotated to 90°, and the elbow was flexed to 90°. Through a posterior approach, the lower end of the humerus was exposed after protecting the ulnar nerve. The initial osteotomy was performed 0.5–1 cm superior to the olecranon fossa, perpendicular to the axis of humerus shaft. The triangular template (turned face downward in view of the posterior approach) was placed over the proximal portion of the humerus, and area it covered was marked with a surgical pen. The proximal part of the humerus was then osteotomized according to the drawn line. In patients with cubitus varus, the lateral edge of the distal fragment was moved into the apex of the proximal osteotomy site, and degree of correction increased as the apex was moved medially. In those with cubitus valgus, the medial edge of the distal fragment was moved into the apex of the proximal osteotomy site, and the degree of correction increased as the apex was moved laterally. This osteotomy also allows correction of the flexion deformity by adding an extension osteotomy to the procedure. After correction of the deformity, temporary Kirschner wire fixation was performed followed by definite fixation with well-contoured Y-shaped stainless steel plate. After fixation, the excised triangular bone was used as supplementary bone graft. The arm was protected in a posterior splint with the elbow in 90° of flexion and the forearm in neutral rotation for 3 weeks. Active range of motion exercises was started 3 weeks after the operation.
An overall clinical evaluation was carried out according to the criteria similar to those of Oppenheim et al.,
| Results|| |
The average age of the patients at the time of osteotomy was 11.6 years (5–22 years) with an average follow-up of 3 years. The average interval from injury to the corrective osteotomy was 4.4 years (1–16 years). There were 19 male and 13 female patients. The right elbow was involved in eight cases and left in 24 cases.
We treated 27 cases of cubitus varus and five cases of cubitus valgus with step-cut translation osteotomy. The results according to the modified criteria of Oppenheim et al., were 25 excellent, six good, and one poor [Table 1].
|Table 1: Results of step-cut osteotomy according to the modified Oppenheim criteria|
Click here to view
Average preoperative HEW angle was 22.9° varus (8–40°). It was corrected to 9.3° valgus (6–15°) with average total correction of 32.2° [Figure 1]. It was symmetric with the unaffected side in 25 out of 27 cases. The mean total arc of elbow motion was 117° (70–140°) preoperatively and 126° (100–145°) postoperatively. The average improvement in the LPI (reduction of the prominence of the lateral condyle) was 21.7% (from −16.2 to 5.5%). There was one case each of implant failure, superficial infection, and myositis ossificans.
|Figure 1: (a) An 8-year-old child with cubitus varus (left). (b) Anteroposterior radiograph showing cubitus varus deformity. (c) Correction of deformity without lateral condyle prominence. (d) Anteroposterior radiograph of elbow showing correction of deformity and fixation with Y plate (note that because of medial translation of distal fragment, there is no undue prominence of lateral condyle of humerus)|
Click here to view
Average preoperative HEW angle was 35.8° valgus (30–44°). It was corrected to 11.4° valgus (10–15°) with average total correction of 24.4° [an example in [Figure 2]. Average difference between carrying angle of operated and normal side was 1° (0–2°). The mean total arc of elbow motion was 113° (90–140°) preoperatively and 118° (90–140°) postoperatively. The average improvement in the MPI was 2.6% (from 0.4 to −2.2%). There was one case of a postoperative tourniquet burn with an unacceptable scar.
|Figure 2: (a) Cubitus valgus deformity (left) in a 20-year-old patient. (b) Anteroposterior radiograph showing cubitus valgus deformity. (c) Postoperative clinical photograph showing correction of deformity. (d) Radiograph showing correction of deformity and fixation of osteotomy site with Y plate|
Click here to view
There was one nonunion with implant failure after 2 months of the osteotomy, which was subsequently revised. The patient was a young enthusiastic athlete who resumed his sporting activities early at 4 weeks without solid union of the osteotomy site. Revision surgery with the same step-cut translation osteotomy was done; however, he developed elbow stiffness with a 30° decrease in the arc of elbow motion and a poor result. One patient had a superficial wound infection that resulted in a hypertrophic scar. Myositis ossificans developed in one case; however, it did not interfere with the postoperative range of motion. Overall, complication rate in our series was 12.5% (4/32).
Cubitus varus is a complex three-dimensional deformity comprising of medial rotation in horizontal plane, hyperextension in the saggital plane, and a varus tilt in the coronal plane; however, the varus component appears to be the one that contributes the most to the cosmetic deformity. In the past, cubitus varus deformity was considered as being only a cosmetic deformity without any functional consequences; however, there are several long-term complications of cubitus varus deformity including increased risk of fracture of lateral condyle or distal humeral physeal fractures, posterior instability of the ipsilateral shoulder, posterolateral instability of the elbow,, and avascular necrosis of the distal humeral epiphysis. The most common late complication of cubitus valgus deformity is tardy ulnar nerve palsy.
Lateral closing wedge osteotomy is the simplest and most commonly done osteotomy for correction of cubitus varus deformity, although it has many technical pitfalls. Under correction, difficulty in rigid fixation, recurrence of deformity, lazy-S deformity, and unsightly scar are few of the complications of lateral closing wedge osteotomy.
The step-cut translation osteotomy is inherently stable and the wide osteotomy surface facilitates an early union of the osteotomy site in 4–6 weeks in most of the cases. Medial translation of the distal fragment corrects the deformity without creation of a prominence of lateral condyle; this along with the posterior scar creates a cosmetically acceptable deformity correction. Medial translation of distal fragment may also stabilize the subluxation of the medial head of triceps and the ulnar nerve. Fixation of the osteotomy site with Y plate provides rigid fixation and allows early mobilization of the elbow; therefore, reducing chances of elbow stiffness. Song et al. emphasizes the importance of maintaining range of movement during treatment to obtain a good functional result. In our study, the elbow was mobilized at an average period of 3 weeks following osteotomy.There was a decrease in the total arc of elbow motion postoperatively in nine out of the 27 patients of cubitus varus and one out of the five patients of cubitus valgus; however, this decrease was ≤5° in six patients. There was an improvement in the arc of elbow motion in 13 out of 27 patients with cubitus varus and three out of five patients with cubitus valgus. This increase in total arc of elbow motion could be because of the changes in the biomechanics of the elbow joint following the osteotomy.
In our study, 62.5% (20/32) of patients were in the age group of 5–12 years at the time of osteotomy with growth remaining. Follow-up shows no recurrence of the deformity and we posit that this osteotomy can be done before the second growth spurt without the fear of recurrence of deformity. However, we accept that long-term follow-up and large case series are required to validate this finding.
Our results demonstrate that a step-cut translation osteotomy has the ability to correct cubitus varus and valgus deformities without any prominence of the medial or lateral condyle in the majority of patients. Moreover, a wide osteotomy surface and rigid fixation allows earlier movement than is possible with other osteotomy techniques. In this series, 96.2% cases of the cubitus varus and all cases of cubitus valgus deformity had excellent-to-good results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Skaggs DL, Glassman D, Weiss JM, Kay RM. A new surgical technique for the treatment of supracondylar humerus fracture malunions in children. J Child Orthop 2011;5:305-12.
Siris IE. Supracondylar fracture of the humerus: Analysis of 330 cases. Surg Gynecol Obstet 1939;68:201-22.
French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. Lancet 1959;2:439-41.
King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg Am 1951;33-A:572-6.
Myint S, Molitor PJ. Dome osteotomy with T-plate fixation for cubitus varus deformity in an adult patient. J R Coll Surg Edinb 1988;43:352-4.
Tien YC, Chen JC, Fu YC, Chih TT, Huang PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. J Bone Joint Surg Am 2005;87:1456-63.
Derosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin Orthop Relat Res 1988;236:160-5.
Kim HT, Lee JS, Yoo CI. Management of cubitus varus and valgus. J Bone Joint Surg Am 2005;87:771-80.
Yamamoto I, Ishii S, Usui M, Ogino T, Kaneda K. Cubitus varus deformity following supracondylar fracture of the humerus: A method for measuring rotational deformity. Clin Orthop Relat Res 1985;(201):179-85.
El-Adl W. The equal limbs lateral closing wedge osteotomy for correction of cubitus varus in children. Acta Orthop Belg 2007;73:580-7.
Oppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res 1984;(188):34-9.
Chung MS, Baek GH. Three-dimensional corrective osteotomy for cubitus varus in adults. J Shoulder Elbow Surg 2003;12:472-5.
Chess DG, Leahey JL, Hyndman JC. Cubitus varus: Significant factors. J Paediatr Orthop 1994;14:190-2.
Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1982;2:539-46.
Davids JR, Maquire MF, Mubarak SJ, Wenger DR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus. J Pediatr Orthop 1994;14:466-70.
Takahara M, Sasaki I, Kimura T, Kato H, Minami A, Oqino T. Second fracture of the distal humerus after varus malunion of a supracondylar fracture in children. J Bone Joint Surg Br 1998;80:791-7.
Abe M, Ishizu T, Morikawa J. Posterolateral rotatory instability of the elbow after posttraumatic cubitus varus. J Shoulder Elbow Surg 1997;6:405-9.
O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H 2nd, Morrey BF et al.
Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001;83:1358-69.
Abe M, Ishizu T, Shirai H, Okamoto M, Onomura T. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg Am 1995;20:5-9.
Griffin PP. Supracondylar fractures of the humerus. Treatment and complications. Pediatr Clin North Am 1975;22:477-86.
Ippolito E, Moneta MR, D’Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am 1990;72:757-65.
Wong HK, Lee EH, Balasubramaniam P. The lateral condylar prominence. A complication of supracondylar osteotomy for cubitus varus. J Bone Joint Surg Br 1990;72:859-61.
Song HR, Cho SH, Jeong ST, Park YJ, Koo KH. Supracondylar osteotomy with Ilizarov fixation for elbow deformities in adults. J Bone Joint Surg Br 1997;79:748-52.
[Figure 1], [Figure 2]