3D-printed model and osteotomy template technique compared with conventional closing-wedge osteotomy in cubitus varus deformity

Step-cut osteotomy for cubitus varus deformity with application of patient-specific instrument in children: a preliminary report

PURPOSE

The step-cut osteotomy has been recognized as a valuable approach for addressing cubitus varus deformity, albeit one that necessitates technical proficiency. This study aims to evaluate the efficacy of the modified step-cut osteotomy technique in conjunction with patient-specific instruments by clinical and radiological assessment.

METHODS

We conducted a retrospective review of patients who underwent modified step-cut osteotomy with the use of patient-specific instruments in conjunction with Kirschner wires fixation for the correction of cubitus varus deformity between April 2016 and April 2022. Follow-up was performed for a minimum of two years, during which pre-operative and post-operative clinical and radiological parameters were compared.

RESULTS

Fifteen patients were enrolled in this study. The mean pre-operative humeral-elbow-wrist (HEW) of the affected side was -21.7° (ranging from -14° to -34°), while the normal side was 9.4° (ranging from 5° to 15°). The post-operation HEW of affected side was 9° (ranging from 4° to 16°). There was no significant difference between the normal side and affected side after operation (p = 0.74). Pre-operative range of motion in the affected side was 130°, while the post-operative range of motion was 132°. Fourteen patients (93.3%) were pleased with the overall appearance of their elbow. None lazy-S deformity was observed in these cases. There were no major complications.

CONCLUSION

The modified step-cut osteotomy technique, utilizing patient-specific instrument in conjunction with Kirschner wires fixation was found to be a safe, reliable, and technically easy procedure for correcting cubitus varus deformity.

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.

Three-dimensional corrective osteotomy for cubitus varus deformity using patient-matched instruments

Background

Various methods of two or three-dimensional (3D) corrective osteotomy for cubitus varus deformity have been reported. However, whether 3D correction of cubitus varus deformity is necessary is controversial because of technical difficulties and surgical complications. This study introduced 3D simulations and printing technology for corrective osteotomy against cubitus varus deformities. Moreover, recent studies on the application of these technologies were reviewed.

Methods

The amount of 3D deformity was calculated based on the difference in 3D shape between the affected side and the contralateral normal side. Patient-matched instruments were created to perform the actual surgery as simulated. Further, a 3D corrective osteotomy was performed using patient-matched instruments for cubitus varus deformity in pediatric and adolescent patients. The humerus-elbow-wrist angle, tilting angle, and elbow ranges of motion were evaluated.

Results

Humerus-elbow-wrist angle and tilting angle were corrected from -21° to 14° and from 30° to 43°, respectively, in the pediatric patient and from -18° to 10° and from 20° to 40°, respectively, in the adolescent patient. The elbow flexion and extension angles changed from 130° to 140° and from 20° to 10°, respectively, in the pediatric patient and from 120° to 130° and from 15° to 0°, respectively, in the adolescent patient.

Conclusion

The 3D computer simulations and the use of patient-matched instruments for cubitus varus deformity are reliable and can facilitate an accurate and safe correction. These technologies can simplify the complexity of 3D surgical procedures and contribute to the standardization of treatment for cubitus varus deformity.

The Role of 3D Custom Implants in Upper Extremity Surgery

SUMMARY

As the technology of three-dimensional (3D) printing becomes more refined and accessible, multiple applications of its use are becoming more commonplace in upper extremity surgery. 3D-printed models have been beneficial in preoperative planning of complex cases of acute trauma or malunions, contributing to spatial understanding or even contouring of implants. Custom guides can also be created to assist intraoperatively with precise placement of osteotomies or arthroplasty implants. Finally, custom 3D implants have been described for cases of bone loss in the upper extremity. This can be for relatively small gaps after malunion correction or extensive defects, typically for trauma or tumor. Articular defects can also be addressed with this technology, although special considerations should be given to the implant design and longevity in these situations. Because of the relatively recent nature of 3D implants, long-term data are lacking. However, they show great promise in an expanding range of challenging clinical indications.

[Comparative study of external fixator combined with Kirschner wire fixation and Kirschner wires fixation in treatment of cubitus varus deformity in children]

Objective

To analyze the effectiveness comparison of external fixator combined with Kirschner wire fixation and Kirschner wire fixation in the treatment of cubitus varus deformity in children.

Methods

A retrospective case-control study was conducted to collect 36 children of postoperative supracondylar humerus fracture complicating cubitus varus deformity between January 2018 and July 2022. Among them, 17 cases were treated with distal humeral wedge osteotomy external fixation combined with Kirschner wire fixation (observation group), and 19 cases were treated with distal humeral wedge osteotomy and Kirschner wire fixation (control group). The baseline data including age, gender, deformity side, time from fracture to operation, carrying angle of the healthy side and preoperative carrying angle of the affected side, elbow flexion and extension range of motion, and lateral condylar prominence index (LCPI) showed no significant difference between the two groups ( P>0.05). The operation time, hospitalization cost, healing time of osteotomy, postoperative complications, and the carrying angle, LCPI, and elbow flexion and extention range of motion were recorded and compared between the two groups. The elbow function was assessed by Oppenheim score at 3 months after operation and at last follow-up.

Results

The children in both groups were followed up 13-48 months, with an average of 26.7 months. There was 1 case of needle tract infection in the observation group and 2 cases in the control group, and no nerve injury occurred, the difference in the incidence of complication (5.88% vs 10.53%) between the two groups was not significant ( χ 2=0.502, P=0.593). There was no significant difference in the operation time and fracture healing time between the two groups ( P>0.05); the hospitalization cost of the observation group was significantly higher than that of the control group ( P<0.05). The Oppenheim score of the observation group was significantly better than that of the control group at 3 months after operation ( P<0.05), but there was no significant difference in the Oppenheim score between the two groups at last follow-up ( P>0.05). At last follow-up, the carrying angle of affected side significantly improved in both groups when compared with preoperative ones ( P<0.05); the differences of the pre- and post-operative carrying angle of affected side and elbow flexion and extension range of motion showed no significant differences between the two groups ( P>0.05), but the difference in pre- and post-operative LCPI of the observation group was significantly better than that of the control group ( P<0.05).

Conclusion

External fixator combined with Kirschner wire fixation and Kirschner wire fixation both can achieve satisfactory correction of cubitus varus deformity in children, and the former can achieve better short-term functional recovery of elbow joint and reduce the incidence of humeral lateral condyle protrusion.

Lateral Collateral Ligament Reconstruction Using the Triceps Brachii Fascia for Posterolateral Rotatory Instability in Cubitus Varus: A Report of Two Cases

A combination of osteotomy and ligament reconstruction is recommended for posterolateral rotatory instability (PLRI) with large cubitus varus deformities. There is a lack of reports regarding ligament donor selection for ligament reconstruction of PLRI with cubitus varus. Two cases of PLRI with cubitus varus have been described. In case one, a 40-year-old woman presented with left elbow pain. She had a cubitus varus deformity, resulting from a childhood elbow fracture. Radiographs showed an 18-degree cubitus varus deformity. A lateral closing wedge osteotomy and double plate osteosynthesis were performed. The lateral collateral ligament (LCL) was reconstructed with autologous triceps fascia. Postoperative radiographs confirmed correction with 10 degrees of the carrying angle (CA). Bone union at the osteotomy site occurred six months later with excellent results. In case two, a 45-year-old man presented an arm with persistent right elbow instability with cubitus varus deformity. This was due to a childhood supracondylar fracture of the right humerus. Radiographs showed a cubitus varus deformity of 25 degrees on the right. The surgical procedure included a lateral wedge osteotomy, double plate fixation, and LCL reconstruction with autologous triceps fascia. Postoperative radiographs confirmed a corrected CA of 5 degrees. Bone union was achieved at the six-month follow-up with satisfactory results. The use of triceps fascia for LCL reconstruction for PLRI due to cubitus varus would provide a minimally invasive and reasonable treatment option.

Research: Construction and validation of elbow function prediction model after supracondylar humerus fracture in children

This article's objectives are to develop a model to predict children's recovery of elbow function following supracondylar fracture, analyze the risk factors affecting those children's elbow function after surgery, and propose a individualized treatment strategy for elbow function in various children. We retrospectively analyzed clinical data from 410 children with supracondylar humerus fracture. A modeling set and a validation set of kids in the included studies were arbitrarily split into 2 groups on a 7:3 basis. To identify statistically significant risk factors, univariate logistic regression analysis was used. Then, multivariate logistic regression was used with the risk factors, and the best logistic regression model was chosen based on sensitivity and accuracy to create a nomogram; A total of 410 children were included in the study according to the inclusion criteria. Among them, there were 248 males and 162 females, and the fracture type: 147 cases of type IIb and 263 cases of type III. There were no significant changes in the afflicted limb's lateral difference, surgical method, onset season, and number of K-wires, according to univariate logistic regression analysis. Age (P < .001), weight (P < .001), height (P < .001), preoperative elbow soft tissue injury (OR = 1.724, 95% CI: 1.040-2.859, P = .035), sex (OR = 2.220, 95% CI: 1.299-3.794, P = .004), fracture classification (Gartland IIb) (OR = 0.252, 95% CI: 0.149-0.426, P < .001), no nerve injury before surgery (OR = 0.304, 95% CI: 0.155-0.596, P = .001), prying technique (OR = 0.464, 95% CI: 0.234-0.920, P = .028), postoperative daily light time > 2 hours (OR = 0.488, 95% CI: 0.249-0.955, P = .036) has a significant difference in univariate analysis; Multivariate regression analysis yielded independent risk factors: fracture classification; No nerve injury before surgery; The daily light duration after surgery was > 2 hours; soft tissue injury; Age, postoperative cast fixation time. The establishment of predictive model is of significance for pediatric orthopedic clinicians in the daily diagnosis and treatment of supracondylar humerus fracture.

Individualized 3D-printed navigation template-assisted tension band wiring for olecranon fractures

PURPOSE

3D printing techniques guide precision medicine and show great development potential in clinical applications. The purpose of this study was to compare the clinical outcomes of 3D-printed navigation templates versus free-hand in tension band wiring (TBW) procedures for olecranon fractures.

METHODS

Patients who underwent TBW due to Mayo type II olecranon fractures between January 2019 and December 2021 in our hospital were prospectively enrolled in the study. The patients were divided into the 3D printed navigation template guiding TBW group (3D printed group) and the free-hand TBW group (free-hand group). The primary endpoint of this study was the success rate of the bicortical placement of Kirschner wires (K-wires). Times of intraoperative fluoroscopy, operation times, complications, VAS scores, and Mayo Elbow Performance Scores (MEPS) were analyzed as the secondary outcomes measure.

RESULTS

The success rate of the bicortical placement of K-wires was 85.7% in the 3D Printed group was significantly higher than the free-hand group (60%). There were fewer times of intraoperative fluoroscopy in the 3D Printed group (1.43 ± 0.51) than that in the free-hand group (2.60 ± 1.00) with statistical significance (P < 0.05). At the date of the last follow-up, four patients suffer from pain and skin injury at the K-wires insertion site in the 3D Printed group and 14 patients in the free-hand group, a significant difference between the two groups (P < 0.05). No statistically significant differences were found in operation time, VAS scores, and MEPS between the two groups.

CONCLUSIONS

The individualized 3D-printed navigation template-assisted TBW demonstrated good accuracy and resulted in reduced times of intraoperative fluoroscopy and complication compared to the free-hand TBW for olecranon fractures.

Guided Growth for the Treatment of Cubitus Varus in Children: Medium- to Long-Term Results

Correction of cubitus varus is commonly attempted through supracondylar humeral osteotomy. We hypothesized that lateral distal humeral hemiepiphysiodesis (LDHH) could be used to gradually correct this deformity in children. We conducted a retrospective study including all patients who underwent LDHH with the eight-Plate system between 2008 and 2018, with a minimum 4-year follow-up. We collected demographic, fracture-related, pre- and postoperative clinical (carrying angle (CA), ROM), and radiological data (humeral-ulnar angle (HUA), Baumann angle (BA), shaft-condylar angle (SCA), lateral capitellohumeral angle (LCHA)), as well as data on complications and satisfaction at last follow-up. Fifteen patients were included, with a median follow-up of 81 (64–103) months. All the variables had improved significantly as follows: CA −16 (−18 to −9)°, HUA −16 (−19 to −12)°, BA −11 (−17 to −7)°, SCA 7.5 (3.3 to 13.8)°, LCHA −4.8 (−6.8 to 0.6), flexion 10 (0 to 24)°, and extension 10 (0 to 10)°. The annual correction rate in terms of HUA was 2.41° (1.9 to 3.2). There were 5 cases of aseptic screw loosening, 4 of them requiring replacement, without relation to age at surgery (p = 0.324). Most patients (86.67%) were satisfied, and a relationship was found with younger age at surgery (p = 0.037). In conclusion, preliminary results show that LDHH with the eight-Plate system is an effective technique for mild to moderate cubitus varus deformity correction in children. Patients should be advised of the relatively long duration of implant retention and the possibility of reoperation for screw replacement or implant removal.