Oblique Lateral Closing-Wedge Osteotomy for Cubitus Varus in Skeletally Immature Patients

Abstract

Background: We perform an oblique lateral closing-wedge osteotomy of the distal end of the humerus to correct cubitus varus deformity in children. This deformity is often the consequence of undertreatment, malreduction, or malunion of supracondylar humeral fractures 1. Although standard arcs of motion may be altered, cosmesis was traditionally considered a primary surgical indication. However, uncorrected cubitus varus leads to posterolateral rotatory instability of the elbow (PLRI) 2 , lateral condylar fractures 3 , snapping medial triceps, and ulnar nerve instability 4. A contemporary understanding of these delayed sequelae has expanded our current indications. Detailed parameters predictive of late sequelae are needed to further specify surgical indications. Description: We remove an oblique lateral closing wedge from the distal end of the humerus via a standard lateral approach. The osteotomy is angled away from the varus joint line such that lateral cortices after reduction lack prominence. Kirschner wires provide adequate fixation in young patients. In older children, extension is simultaneously corrected, and fragments are stabilized via plate osteosynthesis. Alternatives: Patients who decline surgery are counseled regarding risks of delaying treatment until symptoms are present. PLRI manifests as lateral elbow pain or instability while rising from a chair. Once symptomatic, the lateral ulnar collateral ligament (LUCL) is irreversibly attenuated and morphologic changes in the ulnohumeral joint necessitate more extensive surgery to include distal humeral osteotomy, LUCL reconstruction, and possibly ulnar nerve transposition 5. Alternative osteotomy techniques are described and categorized as simple lateral closing wedge, step-cut 6-9 , dome, 3-dimensional 10 , or distraction osteogenesis. Simple closing-wedge osteotomies include a distal cut parallel to the joint line and retain a problematic lateral prominence (if the medial cortex is intact or the distal end of the humerus is not translated medially) 11,12. Step-cut osteotomies theoretically minimize this lateral prominence while enhancing inherent stability. However, these additional cuts mandate wide surgical exposure despite similar outcomes 13. Three-Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSEST/A269).

The lateral curved osteotomy for cubitus varus deformity in children: A case report and literature review

“…Our osteotomy technique is based on the lateral closed wedge osteotomy by French combined with Dome osteotomy, that provides an easy, stable and reproducible result [ [12] , [13] , [14] , [15] ]. The medial open wedge osteotomy is now not recommended since it can lead to instability and elongate the course of ulnar nerve with the risk of late onset of tardy ulnar nerve palsy [ 14 ].…”

“…The medial open wedge osteotomy is now not recommended since it can lead to instability and elongate the course of ulnar nerve with the risk of late onset of tardy ulnar nerve palsy [ 14 ]. The various surgical techniques are well-described in three major features: approach of the elbow, configuration of osteotomy, and fixation technique [ [12] , [13] , [14] , [15] ]. Approach of the elbow: Lateral [ 12 , 13 , [15] , [16] , [17] ], posterolateral [ 10 , 18 ], posterior (triceps splitting) [ 3 , [19] , [20] , [21] ], and posterior approach with Chevron's osteotomy [ 19 ].…”

“…The various surgical techniques are well-described in three major features: approach of the elbow, configuration of osteotomy, and fixation technique [ [12] , [13] , [14] , [15] ]. Approach of the elbow: Lateral [ 12 , 13 , [15] , [16] , [17] ], posterolateral [ 10 , 18 ], posterior (triceps splitting) [ 3 , [19] , [20] , [21] ], and posterior approach with Chevron's osteotomy [ 19 ]. The configuration of osteotomy was described by many literatures, that bear various names on its techniques: French [ 5 , 22 , 23 ], Dome-shaped [ 10 , 19 , 21 , 24 ], Pentalateral [ 16 ], translation step cut [ 3 ], modified step cut [ 2 ], triple modified French [ 12 ], reverse V [ 20 ], dual planar [ 25 ], and multiplanar [ 17 ], lateral closing isosceles triangular [ 15 ], three-dimensional printing assisted [ 26 ], and oblique lateral closing-wedge [ 13 ].…”

“…The comparison of these surgical techniques is often described equally, reporting similar good results with several advantages and disadvantages [ 4 , 17 ]. Fixation technique: Cortical screw then tension band wire [ 5 , 12 , 18 ], K-Wire only [ 2 , 10 , 13 , 18 , 21 , 24 , 27 ], single Y plate [ 3 , 20 ], K-wire then lag screw parallel [ 16 ], buried smooth K-wire [ 25 ], two lateral K-wire [ 15 ], and 3D printing osteotomy guide plate [ 26 ]. …”

“…Approach of the elbow: Lateral [ 12 , 13 , [15] , [16] , [17] ], posterolateral [ 10 , 18 ], posterior (triceps splitting) [ 3 , [19] , [20] , [21] ], and posterior approach with Chevron's osteotomy [ 19 ].…”