Outcome of

Dome Osteotomy for Cubitus Varus Correction in children

___________________________________________________________________
ABSTRACT:

Objective: To analyze the outcomes of dome osteotomy for correction of cubitus

varus deformity.

Methods: We managed 14 children of cubitus varus with dome osteotomy correction

between 7 to 11 years of age. Of these patients 9 were boys and 5 were girls. This

retrospective study was carried out at Combined Military Hospital Abbottabad from

Jan 2011 to June 2012. All patients were followed up 01 year. The main criterion

against which the outcomes were assessed included the range of motion of their

elbow joint, degree of correction of carrying angle and lateral condylar prominence

index.

Results: In light of the assessment criterion the outcome was found to be excellent

in 11 cases and good in 03 patients. Clinical and radiological bone union was

achieved in all cases at 10 weeks. Few complications seen included painful scar

formation, ulnar neurapraxia and pin tract infection. No patient developed lateral

condylar prominence after the surgery.

Conclusion: Dome osteotomy was found to be an exceptional technique to treat

cubitus varus with no resultant iatrogenic deformity of lateral condylar prominence.

Key Words: Outcome, cubitus varus, dome osteotomy.

Introduction

Development of Cubitus varus deformity occurs in neglected or maltreated fractures of

supracondylar part of humerus. 1. It is very unpleasant and generates great anxiety. Most

cases therefore report for surgical correction of this deformity 2. Many corrective

osteotomies have evolved and have been practiced to deal with this pediatric deformity.

However after performing a corrective closing lateral wedge osteotomy it was noticed

that the lateral condyle of the humerus became unduly prominent 3. Multi-centric studies
10.11,12,
were done in this context and nearly all concluded that this end-op cosmetic

appearance was difficult to avoid with the technique of humeral supracondylar lateral

closing wedge osteotomy as the residual distal piece of the humerus inclines laterally in

relation to humeral shaft 8. Because the presence of an unsightly deformity in cubitus

varus was the primary reason of surgery in all the patients hence the lateral closing
5
wedge osteotomy seemingly failed to obtain the desired cosmetic outcomes .

Resultantly a novel surgical technique was introduced which successfully produced the

desired outcomes as reported in the series by Kanaujia et al 6 and Tien et al 7. It required

a dome osteotomy in the deformed distal humeral metaphysis and then moving the

distal fragment in a lateral arc in line with the already calculated angle of correction.

This re-established a normal carrying angle without creating any resultant bump of the

lateral condyle of humerus 8.

Methods

Supracondylar dome osteotomy of humerus was performed in 14 patients. There were

09 boys and 5 girls between 7 to 11 years age. This retrospective study was conducted

at Combined Military Hospital Abbottabad from Jan 2011 to June 2012. Patients
included in the series had cubitus varus deformity (10 Left: 4 Right) due to mal treated

supracondylar humeral fractures. Representative radiographs of the effected elbows

were taken the carrying angles were measured. Mean deformity was found to be 7

degrees varus. Angles of correction were calculated. Dome supracondylar osteotomy

was performed in all cases with cubitus varus deformity according to the technique

described by Tachdjian. Campbell exposure of distal humerus was done. The midline

axis of the elbow and the superior border of the olecranon fossa (point 0) were marked

as the dome center. The 0A segment was considered the base and a line (0B) was

drawn from point 0 to form the calculated angle of correction (a). The segment 0B

formed the radius of the dome, and the required dome was marked with diathermy.

Point B played the starting point of the osteotomy, and a dome was drawn with 0B as

the radius of the arc (Fig .2). After osteotomy the distal fragment was rotated to point A

and fixed with two 2mm Kirschner wires. An augmentative above elbow Plaster of Paris

posterior slab given in 90 degrees elbow flexion for 3 weeks followed by active

movements of the elbow were progressively started. After 1-1.5 months the wires were

removed.

All cases were followed-up to 12 months. Clinical outcomes included measurement of

lateral condylar prominence, final cosmetic appearance, and resultant range of motion.

All complications encountered were recorded.

Results

The patients were evaluated before operation and their range of motion was analyzed

and found normal in 08 patients, 05 patients had hyperextension (7 0 in three and 40 in

two), and one had an extension of 04 degrees. There was improvement in range of
motion after surgery. The extension range was decreased from 10 to 5 0 in 03 patients.

One patient revealed no improvement after correction.

Two boys and one-girl patients developed certain loss of elbow flexion after surgery

(range 5-150, average 6.60). Union was observed at the end of 10 weeks and there was

no failure of fixation or loss of angle of correction as observed postoperatively.

The appearance of elbow after dome osteotomy was excellent in 11 patients and good

in 03 patients. The complications encountered were pin tract infection in 02 patients (1

male & 1 female), which was controlled with oral antibiotics. Two patients developed

hypertrophic scar (2F). One patient (F) had pain in the scar and one patient (M)

developed transient ulnar neurapraxia, which recovered spontaneously in 3 weeks time.

Discussion

Fracture in the supracondylar region of humerus is seen commonly in between the ages

of 2 to 13 years4. If managed conservatively without any correction of the rotational

deformity9 or when mismanaged by quacks then it ends up in cubitus varus. Worldwide

reported incidence of cubitus varus is in between 4% to 21% 10. Many late sequelae

associated with distal humeral fractures are ulnar neuropathy, avascular necrosis of the

distal humeral epiphysis11, secondary distal humeral or lateral condylar fracture 12,

however most patients present with the complaint of an unsightly cubitus varus rather

than any functional disability.13.

In order to correct the cubitus varus various corrective procedures like medial opening

wedge osteotomy15 , arc osteotomy10 , lateral closing-wedge osteotomy 14, and dome

osteotomy,16, have been performed. The most commonly used procedure to correct the
deformity was seen to be the lateral closing-wedge osteotomy of distal humerus 12.

However after this osteotomy it falsely appeared as if the varus deformity still exists

because of the resultant lateral condylar prominence, because when evaluated for this

appearance with radiographs the measured angle formed by the humeral and ulnar

axes (the carrying angle) were same on both sides.

11, 12,14,16,17
Multi-centric studies concluded that this false appearance was because of the

radical shift in the distal fragment of the humerus, relative to the proximal humeral shaft,
16, 17
thereby causing a protrusion of the lateral humeral condyle. . Excision of the wedge

from lateral distal humerus effectively produced two fragments of unequal width and

hence closing the osteotomy compromised the final cosmetic outcome. . 9, 12, 15.In order to

overcome this disappointing outcome Tachdjian 13 carried out dome osteotomy for
6
correction of cubitus varus, reproduced also in series of Kanaujia et al and Tien et al 7.

In dome osteotomy the center of rotation of the distal fragment was taken as the midline

of the humerus and therefore the varus forces acting at the osteotomy site were much

less and made the osteotomy mechanically more stable. In essence Dome osteotomy

uses the center of humeral mechanical axis as the rotation center thereby preventing

the para midline shift of lateral condyle and thereby preventing it from becoming

prominent after the surgery.

CONCLUSION

We conclude that dome osteotomy is an excellent procedure for successful correction of

cubitus varus and found to be an exceptional technique with no resultant iatrogenic

deformity of lateral condylar prominence.

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