|Year : 2018 | Volume
| Issue : 1 | Page : 38-42
Dome osteotomy in cubitus varus: Our results
Ashutosh Kumar, Vidya Sagar, Pawan Kumar, Deepak Kumar, Ritesh Runu, Gaurav Khemka
Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Web Publication||28-Dec-2018|
Dr. Vidya Sagar
Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna 800014, Bihar
Source of Support: None, Conflict of Interest: None
Introduction: Cubitus varus (gunstock deformity) is the most common complication of supracondylar fracture of the humerus. Several osteotomies and various fixation techniques are described for its correction. The most commonly used is the lateral closing-wedge osteotomy, also known as French osteotomy with variable results. Persistent lateral condyle prominence leads to cosmetically unacceptable appearance and poor patient satisfaction. To avoid this problem, dome osteotomy is performed. We have evaluated results of dome osteotomy in our population. Material and Methods: This was a retrospective study carried out in our institute. Ten patients with cubitus varus treated by dome osteotomy were evaluated at 24 months. All patients were operated by triceps-splitting approach. Pre- and postoperative carrying angle of elbow, range of motion, and lateral condyle prominence index were compared according to Banerjee criteria. Results: Ten patients with average age of 9.1 years were followed up for 2 years. Mean gap between injury and surgery was 15 months. Postoperative improvement in carrying angle and lateral condylar prominence index was significant. One case developed ulnar neuropraxia, which recovered fully within 2 weeks. Pin tract infection was seen in three cases and skin infections in two cases. Conclusion: Dome osteotomy is a technically demanding surgery. The functional and cosmetic correction is better compared to that for French osteotomy.
Keywords: Cubitus varus, dome osteotomy, French osteotomy, lateral condyle prominence index
|How to cite this article:|
Kumar A, Sagar V, Kumar P, Kumar D, Runu R, Khemka G. Dome osteotomy in cubitus varus: Our results. J Orthop Dis Traumatol 2018;1:38-42
|How to cite this URL:|
Kumar A, Sagar V, Kumar P, Kumar D, Runu R, Khemka G. Dome osteotomy in cubitus varus: Our results. J Orthop Dis Traumatol [serial online] 2018 [cited 2023 Jun 4];1:38-42. Available from: https://jodt.org/text.asp?2018/1/1/38/248902
| Introduction|| |
Cubitus varus or “gunstock deformity” is a common long-term complication of supracondylar fracture of humerus in children. It is a triplanar deformity due to medial rotation, medial angulation, and hyperextension of distal fragment. The deformity is usually static in case of pure metaphyseal injury, whereas it is progressive due to medial physeal arrest. Lateral condyle prominence (LCP) of distal humerus is the main cosmetic concern of the patient undergoing surgery for cubitus varus . Several surgical techniques such as lateral close wedge, medial open wedge, and step-cut osteotomies are performed with variable results.,,,,,,,,, The correction of LCP is inadequate in wedge osteotomies.,Several authors evaluated the results of dome osteotomy and reported good results.,,,,,,,, We conducted the present study to evaluate the results of fixation technique in dome osteotomy.
| Materials and Methods|| |
This was a retrospective study conducted in a tertiary level teaching hospital for 3 years. Ten children of more than 5 years of age with nonprogressive cubitus varus were included. Patients with congenital deformity, sepsis around elbow joint, multiple injuries, neurological disorder, and metabolic disorders were excluded.
The patients were clinically examined for carrying angle [[Figure 1], range of motion, and neurological status of the limb. The radiological assessment was performed by measuring carrying angle [Figure 2] and lateral condyle prominence index (LCPI) [Figure 3] was measured as described by Wong et al..
|Figure 1: Clinically carrying angle measure by the border of the fully supinated forearm and the long axis of the humerus when the elbow is fully extended|
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|Figure 2: Carrying angle/humerus–ulnar angle (HUA)/humerus–elbow–wrist angle (HEWA) is the angle between the midhumeral and the ulnar axes|
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|Figure 3: The lateral condyle prominence index (LCPI) = (AB − BC)/AC. There is normally a slight medial prominence, the LP being predominantly negative. The more “positive” the LCPI, the more prominent the lateral condyle|
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Banerjee scoring criteria was used for evaluation of results [Table 1]. Preoperative planning was carried out with X-rays, anteroposterior and lateral view, of both elbows [Figure 4]. In all patients, humerus–elbow–wrist angle was measured on both the sides and the correction needed was calculated.
|Table 1: Banerjee criteria for assessment of dome osteotomy in cubitus varus|
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|Figure 4: Skiagram showing alignment X-ray of upper limb. Anteroposterior and lateral view of affected limb|
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| Surgical Procedure|| |
After preoperative planning, informed consent, and pre anaesthetics check-up fitness, surgery was planned under general anesthesia. The patient was placed in lateral position with arm supported with sandbag and forearm hanging with elbow at 90° flexion. Pneumatic tourniquets were used, midline posterior incision was given, and triceps-splitting approach was used in all cases. Ulnar nerve was identified, exposed proximally, and protected with wet gauze during the operation. The perichondrium–periosteum junction was identified, which is present just above the lateral condylar cartilaginous area in the distal humerus. Thick portion of periosteum was detached carefully to avoid trauma to perichondrium and physis.
Preoperatively, angle to be corrected was measured by goniometer and template was made by (stainless steel) s-s wire and autoclaved. Preoperatively drawn template of s-s wire was placed over the posterior aspect of the humerus to match OA line with the periosteum–perichondrium junction of the distal humerus of lateral side. Point “A,” point “B,” and the dome of the osteotomy were then marked with help of cautery [Figure 5]. During the osteotomy, the neurovascular bundles in the anterior cubital fossa were protected carefully. Multiple drill holes were made along the marked osteotomy site by drilling through the anterior and posterior cortices of the humerus, and osteotomy was completed with a narrow osteotome. Distal fragment was then rotated along the arc till points “A” and “B” overlapped. Clinically, the elbow was assessed for correction. Osteotomy site was fixed with 3.5mm narrow DCP, recon plate or K- wires.
|Figure 5: Supracondylar dome osteotomy as described by Tien et al. Intraoperative correction of deformity|
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Follow-up: At 3 weeks, plaster slab and stitches were removed, and gentle active elbow movement was encouraged. K wires were removed after 6 weeks. Clinical and radiological assessments were done at 6 weeks, 12 weeks, 6 months, 12 months, 18 months, and 24 months [Figure 6].
|Figure 6: Pre- and post-op clinical and radiological assessment of dome osteotomy|
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| Results|| |
Ten children (seven males, three females) with cubitus varus were enrolled for the study. Average age was 9.1 years (range, 6–15 years). Left elbow was involved in six (60%) and right elbow in four (40%) children. Mean time gap between injury and surgery was 15 months (range, 10–20 months). Preoperative carrying angle of normal side ranged from 8° to 14° (mean, 10.4°) and affected side ranged from −24° to −15° (mean, −20.1°). Postoperative carrying angle was 6°–10° (mean, +8.2°). Preoperative LCPI ranged from 2.5% to 4.5% (mean, 3.5%). Postoperative LCPI was 2%–2.7% (mean, 2.3%) There was no loss of range of motion postoperatively [Table 2]. One case had ulnar neuropraxia in the early postoperative period, which recovered fully within 2 weeks. Pin tract infection was seen in three cases and skin infections in two cases. The lesion healed with oral antibiotics and dressing. As per Banerjee criteria, all patients showed excellent to good results. No patients had poor outcome [Table 1].
| Discussion|| |
Cubitus varus is a common delayed complication of supracondylar fracture of humerus in childhood. Untreated cubitus varus has no effect on the function of elbow; hence, it is usually ignored. However, it has a definitive impact on cosmetic appearance. Males are mostly affected as seen in the present study, though some studies have an equal incidence in males and females.,It may be due to more outdoor activity in males.
In the present study, majority (70%) of the cases were from rural areas. Most of these patients were treated conservatively in rural setup due to late reporting and poor financial condition. This leads to high incidence of cubitus varus in patients from rural areas.
In the present study, left side was more commonly involved as compared to right side. This is in accordance with the reported classical feature of the supracondylar fractures that mostly occur on nondominant limb.
Owing to cosmetic concern, several types of osteotomies are described for correction.,,,,,,,,,, Most commonly performed is lateral closing-wedge osteotomy. The results of closing wedge have been variable as seen in literature.,Most common problem with lateral closing-wedge osteotomy was persistent LCP. This was first quantified by Wong et al. Because the axis of correction should pass through the center of rotation of angulation (CORA) for realignment of distal and proximal mechanical axis after the osteotomy, geometrically unsound correction leads to lazy S deformity. This is usually seen in case of lateral closing-wedge osteotomy. In dome osteotomy, the correction is performed from CORA, hence complete correction is achieved and LCP is less evident. Several types of dome osteotomies were described with similar results.,,,,The technical difficulties in operation and triceps splitting are the main concerns in dome osteotomy compared to lateral closing-wedge osteotomy. But proper preoperative planning and stable fixation lead to better results in dome osteotomy compared to closed wedge osteotomy.,In our study, both K wires and plate were used. The results were better in K-wire cases, which may be due to large osteotomy area that provides stability even with K wires and less soft-tissue dissection.
The limitations of the present study are small number of subjects, random allocation of K wire and plate fixation, and retrospective analysis. Poor reporting is the main reason for less number of cases. Compared to previous studies, the results are same except fixation method that was not studied earlier. Our study focused on fixation technique and the results were favorable for K wires.
| Conclusion|| |
Dome osteotomy is a simple, safe, and technically better procedure for cubitus varus correction. The chance of LCP is less and yields a near-normal cosmetic outcome. K wire is the better fixation technique compared to plate fixation in dome osteotomy.
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|| |
Verka PS, Kejariwal U, Singh B. Management of cubitus varus deformity in children by closed dome osteotomy. J Clin Diagn Res 2017;1:RC08-12.
Bellemore MC, Barrett IR, Middleton RWD: Supracondylar osteotomy of the humerus with correction of cubitus varus. J Bone Joint Surg 1984;1:566.
Kumar D, Singh S, Kumar S, Srikant TH, Rai T. Clinical outcome of dome osteotomy in cubitus varus. MOJ Orthop Rheumatol 2014;1:00022.
Gwark J, Im J, Park HB. Clinical results of supracondylar dome osteotomy for cubitus varus and valgus deformities in adults. Clin Shoulder Elbow 2016;1:229-36.
Kanaujia RR, Ikuta Y, Muneshige H, Higaki T, Shimogaki K. Dome osteotomy for cubitus varus in children. Acta Orthop Scand 1988;1:314-17.
Akhtar M, Nadeem RD, Khalid MU, Mumtaz R, Wasim S, Anwer U. Focal dome osteotomy for correction of varus deformity at elbow in children. J Pak Med Assoc 2015;1:S115-8.
Kumar K, Sharma VK, Sharma R, Maffulli N. Correction of cubitus varus by French or dome osteotomy: A comparative study. J Trauma 2000;1:717-21.
Wong HK, Lee EH, Balasubramaniam P. The lateral condylar prominence. A complication of supracondylar osteotomy for cubitus varus. J Bone Joint Surg Br 1990;1:859-61.
Davids JR, Lamoreaux DC, Brooker RC, Tanner SL, Westberry DE. Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus. J Pediatr Orthop 2011;1:353-65.
Pankaj A, Dua A, Malhotra R, Bhan S. Dome osteotomy for posttraumatic cubitus varus: A surgical technique to avoid lateral condylar prominence. J Pediatr Orthop 2006;1:61-6.
Raney EM, Thielen Z, Gregory S, Sobralske M. Complications of supracondylar osteotomies for cubitus varus. J Pediatr Orthop 2012;1:232-40.
North D, Held M, Dix-Peek S, Hoffman EB. French osteotomy for cubitus varus in children: A long-term study over 27 years. J Pediatr Orthop 2016;1:19-24.
Cho CH, Song KS, Min BW, Bae KC, Lee KJ. Long-term results of remodeling of lateral condylar prominence after lateral closed-wedge osteotomy for cubitus varus. J Shoulder Elbow Surg 2009;1:478-83.
Banerjee S, Sabui KK, Mondal J, Raj SJ, Pal DK. Corrective dome osteotomy using the paratricipital (triceps-sparing) approach for cubitus varus deformity in children. J Pediatr Orthop 2012;1:385-93.
Høyer A. Treatment of supracondylar fracture of the humerus by skeletal traction in an abduction splint. J Bone Joint Surg Am 1952;1:623-37.
Cheng JC, Lam TP, Shen WY. Closed reduction and percutaneous pinning for type III displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1995;1:511-5.
Tien YC, Chih HW, Lin GT. Dome corrective osteotomy for cubitus varus deformity. Clin Orthop Relat Res 2000;1:158-66.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]