Relationship of cubitus varus and ulnar varus deformity in supracondylar humeral fractures according to the age at injury

Computer-simulated mirror osteotomy in the treatment of post-traumatic cubitus varus deformity in children

PURPOSE

To explore the feasibility and early clinical efficacy of computer-based mirroring technology in simulating osteotomy for the treatment of post-traumatic cubitus varus deformity in children.

METHODS

A retrospective analysis was conducted on the data of 26 patients with cubitus varus deformity who were admitted between June 2019 and June 2024. Among them, there were 19 males and 7 females, with an average age of 8.12 ± 2.83 years (ranging from 5 to 15 years). The time from injury to surgery ranged from 13 to 84 months, averaging at 27.85 ± 21.91 months. The carrying angle and anteversion measured on full-length anteroposterior radiographs of both upper extremities and lateral radiographs of the elbow joint were used as osteotomy parameters. Low-dose CT scans of both upper extremities of the pediatric patients were performed to reconstruct three-dimensional (3D) models of the affected limb for computer-simulated osteotomy. The 3D mirror-imaging technique of the unaffected side was applied for overlay comparison, and the osteotomy parameters were adjusted accordingly. Surgeries were performed based on the final parameters obtained. Intraoperative data such as surgical duration and blood loss were recorded, and regular postoperative follow-ups were conducted with X-ray examinations to observe bone callus formation in the osteotomy area. At the final follow-up, the carrying angle, anteversion, and range of motion (flexion and extension) of the elbow joints on both the affected and unaffected sides were measured, and elbow function was assessed using the Mayo score.

RESULTS

The surgical duration for the 26 patients ranged from 35 to 55 min, averaging at 44.23 ± 7.83 min, with an average blood loss of 32.12 ± 6.35 ml (ranging from 20 to 40 ml). The mean follow-up duration was 31.12 ± 15.81 months (ranging from 6 to 60 months). Kirschner wires (K-wires) were removed 8-12 weeks postoperatively, and plates were taken out 4-6 months later. During the follow-up period, two patients experienced pin tract irritation symptoms after K-wire fixation, which improved after dressing changes; one patient had poor plate adherence causing skin irritation and recovered after early removal of the internal fixation. No complications such as fracture or loosening of the internal fixation devices occurred. At the final follow-up, the carrying angle of the affected elbow joint was (13.48 ± 4.19) °, the anteversion was (44.08 ± 3.80) °, the flexion was (143.27 ± 1.51) °, and the extension was (-7.23 ± 1.63) °. These values were significantly improved compared to those before surgery and showed no significant difference compared to the unaffected side. According to the Mayo Elbow Performance Score, 24 patients were rated as excellent and 2 as good.

CONCLUSION

Using computer-based mirroring technology for osteotomy simulation enables precise bone resection, which not only shortens the surgical duration but also makes the surgical procedure easier to operate, with satisfactory clinical treatment outcomes in the short-term.

Locking plate versus K-wires and cast fixation in lateral closing-wedge osteotomy for cubitus varus deformity

Background

The aim of this study was to assess the clinical and radiographic outcomes of cubitus varus treatments based on different fixation methods: Locking plate vs. Kirschner-wires (K-wires) and cast fixation.

Methods

This retrospective study of 28 patients was performed in lateral-wedge osteotomy for cubitus varus deformity in our hospital from July 2018 to July 2020. 14 patients in group A were treated by locking plate after lateral closing-wedge osteotomy, whereas other 14 patients were treated by K-wires in group B. We measured the bony union and carrying angle. The clinical and radiographic outcomes were assessed according to the Bellemore criteria.

Results

No nonunion, neurovascular injury or myositis ossificans was noted at follow-up. In group A, 1 patient with lateral condylar prominence was found. In group B, 2 patients with pinning site infection were treated successfully with oral antibiotics and 2 patients needed revision surgery for residual varus. According to the Bellemore criteria, statistically significant difference was noted between the two groups (P = 0.0458). In the present study, no statistically significant difference was noted in the length of incision and operation time between the 2 groups (P > 0.05). However, the postoperative carrying angle was significantly different at final follow-up between the 2 groups (P < 0.01).

Conclusions

Compared with K-wires and cast fixation, we recommend the wedge osteotomy with lateral locking plate to treat the cubitus varus deformity because locking plate could achieve better functional and cosmetic results and stabilize the distal humerus rigidly.

Distal humeral osteotomy for cubitus varus in children compared to adolescents

Background

While pediatric cubitus varus has often been considered merely a cosmetic deformity, long-standing cubitus varus can lead to symptomatic pain and elbow instability in adults and may present as early as adolescence. The purpose of this study was to compare patient and radiographic characteristics, surgical factors, and symptom resolution after distal humeral osteotomy for cubitus varus in pediatric versus adolescent patients.

Methods

This is a retrospective single-institution review of 17 patients (12 patients <10.0 years (group Peds); 5 patients >10.0 years (group Adol)) were treated for cubitus varus with distal humeral osteotomy from 2003 to 2019. Peds had a median age of 6.3 years (range, 2.7-7.8 years) at the time of osteotomy, and Adol had a median age of 14.1 years (range, 13.5-16.7 years). A Fisher's exact test was used to compare categorical variables between Peds and Adol, and continuous variables were compared using Mann-Whitney or Student's t-test depending on normality results using the Shapiro-Wilk test. Statistical significance was set at P<.05.

Results

Preoperative pain was present in 17% (2/12) of Pediatric patients (Peds) but 100% (5/5) of Adolescent patients (Adols). Mechanical symptoms were present in 17% (2/12) of Peds and 80% (4/5) in Adol. Radiographic correction and final range of motion did not significantly differ between the 2 groups. The mean tourniquet time was 83 minutes in Peds and 117 minutes in Adol. Pin fixation was used in 100% (12/12) of Peds; 80% (4/5) of Adol had plates. At the final follow-up, all Peds had resolution of symptoms, but 60% (3/5) Adol had continued pain and mechanical symptoms.

Conclusions

Although both pediatric and adolescent patients have similar radiographic correction and range of motion after distal humeral osteotomy to correct cubitus varus, the surgery may be more technically difficult in adolescent patients, with longer tourniquet times and the use of plate instead of pin fixation. Adolescents should be counseled that, like adults, their symptoms may not completely resolve after correction of radiographic and clinical deformity. The authors recommend that cubitus varus be corrected in childhood prior to the development of symptoms in adolescence.

Key Concepts

1)Cubitus varus following pediatric distal humerus fracture may present with pain and mechanical symptoms as early as adolescence.2)Although pediatric and adolescent patients may have similar radiographic correction and range of motion after distal humeral osteotomy, the surgery is technically more difficult in adolescent patients.3)Adolescents should be counseled that pre-operative symptoms may not completely resolve after correction of radiographic and clinical limb deformity.4)It is the authors' opinion that cubitus varus should be surgically corrected before a child reaches adolescence, when it is technically less demanding and before mechanical symptoms and pain develop.

Level of Evidence

Level III - Retrospective Cohort Study.

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.

Computer-Aided Planning and 3D-Printed Surgical Guide in Patients with Extreme Cubitus Varus Deformity: A Report of 2 Cases

CASE

We describe 2 patients with extreme triplanar cubitus varus deformity, treated with step-cut corrective virtually planned osteotomies and performed with custom-made surgical guides. The surgery was simulated on the patients' bone 3D-printed model to verify the effectiveness of the surgical plans. At a medium 21-month follow-up after surgery, in both patients, clinical and radiological results were fully satisfactory, and no complications have been reported.

CONCLUSION

The precision of computer-aided surgical planning and custom-made surgical guides allow to perform reproducible and relatively safe surgeries even in extreme deformities where the surgical complexity could discourage attempts at surgical correction.

COMPARISON OF TWO METHODS OF FIXATION OF SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN

Objective:

To compare the outcomes of the fixation of complete and displaced supracondylar humeral fractures in children with two different Kirschner wire configurations.

Methods:

The type of fixation was randomized to either crossed (19 cases), or two divergent lateral Kirschner wires (24 cases). The comparison was made six months later between the two treated groups and each group with the non-fractured elbow (clinical alignment, range of motion, Baumann angle, and lateral humeral capitellar angle).

Results:

43 children were evaluated (65% boys) with a mean age of six years and five months. The carrying angle (p = 0.94), extension (p = 0.89), and the Flynn´s criteria (p = 0.56) were similar between the groups. The flexion was slightly smaller for the crossed wire group (p = 0.04), but similar to the uninjured side. The Baumann angle was not different between the two fixations (p = 0.79) and the contralateral side (p = 0.1). The lateral humeral capitellar angle was slightly greater for the lateral pinning (p = 0.08), but with no difference with the uninjured elbow (p = 0.62). No iatrogenic injuries were observed.

Conclusion:

Both fixations presented similar outcomes that did not significantly affect the carrying angle in relation to the non-fractured side. Level of evidence II, Therapeutic study - Investigating the results of treatment.

Not Kidding! Sequalae of elbow trauma in children

Elbow injuries are common in children and while majority heal very well, some result in deformities of the elbow. Although deformities such as cubitus varus and non-progressive cubitus valgus are considered cosmetic by the paediatric orthopaedic surgeons and intentionally ignored, they are not always benign and can result in functional deficit due to instability, pain, tardy nerve palsies and osteoarthritis later in life. Similarly congenital and developmental conditions that do not cause major functional loss in childhood, become very disabling in adults due to increasing functional demands. Congenital radial head dislocation and radioulnar synostosis fall into this category. In this paper we discuss clinical presentation, treatment options and outcomes of common elbow conditions presenting later in the life.

Early correction of malunited supracondylar humerus fractures in young children

INTRODUCTION

Supracondylar fracture malunion usually results in cubitus varus deformity. The long-standing unsightly deformity causes psychological stress to the child and his/her parents in addition to biomechanical disturbances and functional disorders in the affected elbow. The optimal timing of corrective osteotomy is not well-established in the literature. The present study aimed to report the results of early correction of cubitus varus deformity using a simple technique and to focus on the timing of early correction after supracondylar fracture malunion.

PATIENTS AND METHODS

Thirty consecutive patients treated for recent cubitus varus deformity after malunited supracondylar fractures, in the period between January 2012 and August 2017, were retrospectively reviewed. All patients had early surgical correction of the deformity within one year after the initial injury. In patients who presented with maluniting supracondylar fracture, the fracture was splinted until union was achieved, then active exercises were encouraged until elbow ROM was regained. The deformity was then corrected with a lateral closing wedge (LCW) osteotomy and fixed with two lateral and one medial wire.

RESULTS

All the osteotomies united. All the deformities were corrected. The humerus-elbow-wrist (HEW) angle significantly improved compared to the pre-operative values (p<0.001). All patients achieved satisfactory results at the final evaluation. Twenty-six patients (86.7%) achieved excellent results while four patients (13.3%) achieved good results.

CONCLUSION

Early correction of cubitus varus deformity avoids the psychological stress of the long-standing unsightly deformity to the young child and his/her family. It also avoids the delayed biomechanical and functional disturbances to the affected elbow. The LCW osteotomy and the three-wires fixation technique are simple and effective to correct the deformity and maintain the correction.

Cubitus Varus-It's More Than Just a Crooked Arm!

Although cubitus varus has been regarded as a purely cosmetic problem in the pediatric population, symptomatic elbow instability, and ulnar neuropathy from the mechanical axis malalignment have been reported in adults. This overview discusses the biomechanical axis disruption that leads to soft tissue and morphologic bony alterations in the elbow and offers a compelling argument for corrective osteotomy to treat pediatric cubitus varus.