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Year : 2016 | Volume : 4 | Issue : 3 | Page : 150 - 154  


Original Articles
Modified French osteotomy of humerus for post traumatic cubitus varus

Prabhakar YVS 1, Srinivasan N 2

 

1Associate Professor of Orthopedics, Malla Reddy Medical College for Women, Hyderabad

2Professor & HOD of Orthopedics, Malla Reddy Institute of Medical Sciences, Hyderabad

Corresponding Author:

Dr. Prabhakar YVS                                                                                                                                             Received: 03-04-2015

Email: prabhakaryerramilli@gmail.com                                                                                                        Accepted: 05-02-2016

 

 

Abstract:

Background: The cubitus varus is the most common long term complication of the supra-condylar fractures of the humerus in children .Though the deformity is considered to be more of cosmetic in nature, recent studies have also described an associated morbidity .In the past the incidence of the cubitus varus following the supra condylar fractures ranged from 9% to 58%.However with the use of the modern methods of management of the fractures, the incidence has decreased. Several methods of correction of the cubitus varus have been in vogue. They differ mostly in their approach and the methods of fixation. Objective: To evaluate the modified French osteotomy technique. Methods: 14 patients in the age group of 7 and 23 were operated for correction of cubitus varus deformity, at a primary orthopedic care hospital in rural Telangana and followed up for mean period 2.4 years. We used a slight modification of the modified French technique and found it to be of advantage in our series. Results: Our results were graded as per the functional grading used by Bellimore.79% of our patients showed excellent results. Our results compare favorably with the results from the other series. Conclusion: The modified French osteotomy is simple safest and most stable osteotomy which can be performed by orthopedic surgeons with the basic knowledge of the patho-anatomy and biomechanics of the deformity, with favorable and comparable results.

Key words: cubitus varus, Modified French osteotomy, rural hospital

INTRODUCTION:

 

The cubitus varus is the most common long term complication of the supra condylar fractures of the humerus in children. The treatment of the deformity is considered to be more of cosmetics. But other studies have described an associated morbidity for which surgical intervention is necessary. The incidence of the cubitus varus following the supra condylar fractures ranged from 9% to 58%.However with the use of the modern methods of management of the fractures based on Garland’s classification and surgical intervention wherever is necessary, the incidence has decreased. This deformity consists of a permanent adduction of the forearm, which is most apparent when the elbow is in full extension. The most prominent feature is the marked, abrupt, movement made by the forearm towards the ulnar side as the limb approaches full extension, and the unsightly appearance of the limb in this position. (1) The deformity is predominantly cosmetic The functional is found in major degree of cubitus varus while walking in the inability to clear pelvis and pain during lifting weights.

Several methods of corrective osteotomies were described which differ both in their approach as well as their fixation techniques. A) The Medial open wedge osteotomy, with bone grafting. Here the disadvantages are a gain in length and ulnar nerve neuropathy. (2) B) oblique osteotomy with derotation fixed with cortical screws attempts to correct a two plane deformity with a single osteotomy. (3) C) Three dimensional osteotomy in which medial and posterior tilt and rotation are corrected (4) D) Lateral closed wedge osteotomy is inherently stable, the easiest and the safest. The methods of fixation included two screws & figure of eight wire, compression plate fixation, crossed kirschner wires and staples. Kirschner wire fixation was the most prevalent method of holding the osteotomy. Loosening of the fixation, pin track infection, skin sloughing and nerve palsies and rarely aneurysm of brachial artery were noted. (5) E) Uni-planar supra condylar closing wedge osteotomy with pre set kirschner wires in post traumatic cubitus varus was reported in 36 patients with good results. (6) F) French and modified French osteotomy: here Lateral closed wedge osteotomy is used to correct the post traumatic cubitus varus. The osteotomy is stabilized using two screws over which wire loop is tightened. Posterior approach is used in the French technique and the triceps is cut from its insertion. In modified French osteotomy the postero lateral approach is used and the lateral one third muscles is slit rather than cut. It is muscle preserving surgery and helps in early rehabilitation. (7)

In the present series we have used a slight modification to the modified French osteotomy of Bellimore et al. In our correction we have used a lateral approach in supine position and found no problems in the surgical technique.

 

MATERIAL AND METHODS

This is a prospective study undertaken by a single orthopedic surgeon at a primary rural orthopedic center between 2005 and 2012.14 patients of post traumatic cubitus varus were operated during this period by Modified French osteotomy and osteotomy stabilized by two screws and bound by figure of eight Stain less steel wire. Informed consent was taken from the parents before the study was under taken Patients with gross elbow stiffness, myositis ossificans due to massaging, failed surgery and evidence of osteomylitis, neurological deficits and ischemic muscle contractures were excluded from study. Deformities with less than -5 degrees of varus were also not included in the study. Included were the patients with post traumatic cubitus varus due to mal-united supra-condylar fractures with or without prior orthopedic intervention.

Five of our patients were treated by closed manipulation and plaster cast immobilization elsewhere and subsequently developed the deformity. The rest were treated by local quacks by indigenous methods. These patients had a limitation of range of movements at presentation, in addition to the deformity. The age at the time of presentation was 7 years to 23 years. The female patients were noted to be presenting at an early age because of a bad cosmetic appearance of the deformity. There were 9 males and 5 female patients and 6 right and 8 left elbows in our series.

All the patients were thoroughly examined at presentation, both clinically and radiologically. Radiographs of the deformed and the normal limb were taken in antero-posterior and lateral views for comparison The size of the wedge of the bone to be removed is determined pre-operatively by obtaining the radiographs of both the elbows in full supination and extension of the elbow. The tracing of the normal elbow is super imposed on the deformed elbow to get the idea of the wedge to be resected at the time of surgery

The patients were counseled that the surgery is primarily cosmetic and may or may not improve the range of movements. Expectation of an improved range of movement from surgery by the patient or surgeon would be superfluous. Patients with <90 degrees of flexion were encouraged to undergo physiotherapy and maximum range of movement possible is obtained prior to surgery.

SURGICAL PROCEDURE

We prefer to perform the procedure in supine position and under general anesthesia. An Eschmark’s tourniquet is used to make the procedure as blood less as possible. A lateral incision is taken along the lateral condylar ridge starting from the lateral epicondyle proximally for 8 to 10 cm. The triceps is neither cut nor split but detached sub- periosteally from the bone and retracted posteriorly. The anterior soft tissues the brachialis and the biceps are also retracted anteriorly after sub-periosteal dissection. Now the entire anterior, lateral and the posterior surfaces of the supra-condylar region of the humerus are visible. Two drill holes are made to act as the guides in making the wedge osteotomy. The distal cut is made as close to the olecrenon as possible, proximal to the coronoid fossa. The size of the wedge to be cut is determined preoperatively as described earlier. Two screws were inserted one in the proximal fragment of the proposed cut and other in the distal fragment. The distal screw is placed in the anterior half of the distal fragment. The wedge of the bone is cut with an oscillating saw leaving the apex intact at the medial cortex The wedge is removed and the medial cortex is fractured leaving a periosteal hinge, in full extension and supination of the elbow The carrying angle and the rotation deformities are evaluated and if found satisfactory a wire loop is tightened around the screw heads to oppose the cut surfaces

The tourniquet is released, hemostasis is secured and the wounds were closed. We have not used the closed drain routinely.

ADVANTAGES OF OUR PROCEDURE

Our technique slightly differs from the French technique and the modified French technique. It is done in a supine position avoiding the cumbersome prone and lateral decubitus positions which are convenient to anesthesiologist also. It helps in the correction of the carrying angle and the rotation deformity under direct vision as we can compare the alignment with the normal opposite limb. Our approach also avoids the cutting of the triceps that’s described in the French procedure. This helps in early rehabilitation of the patient post operatively

 

RESULTS AND DISCUSSION:  

A In the present series we had operated on a 14 patient with post traumatic cubitus varus by a modified French technique as described by Bellimore et al in the year 1984. We followed the principals as enunciated by Bellimore but we approached the osteotomy from a lateral approach as different from the posterolateral approach by Bellimore. The patients were of the age group of 5 and 23, and presented to us after an average time period of 3 1/2 years from the time of injury. They were of both sexes with 9 males and 5 females. The carrying angle , range of movements of the elbow were assessed preoperatively and post operatively at 6weeks,3 months , 6 months and subsequent reviews. The lateral condylar prominence index was post operatively assessed. All the patients were followed up for a mean period of 2.4 years with range 7 months to 3.4 years. One patient was lost to follow up.

The results were graded as per the functional grading using Bellimore criteria

 

 

 

 

 

Out- come

Pre  & post op ROM

Carrying angle

LCPI

Complications

Excellent

Difference<10

Difference

5-6 degrees

No increase

None

Good

Difference10-20

Difference

6-10 degrees

 

Increase, 25%

Minor

Poor

Difference >20

Difference

>10 degrees

Increase

>25%

Residual deformity

Re do surgery

We had operated on 14 patients of post traumatic cubitus varus by a modified French lateral closed osteotomy. The patients were followed up for mean period 2.4 years one patient was lost to follow up. 12 patients had satisfactory cosmetic results and one had poor correction of the deformity due to loss of correction post operatively. The radiological union at the osteotomy site took place in a mean period of 6.5 weeks (range 5.5 to 8 weeks) ten of our patients could achieve preoperative range of flexion without further loss of flexion.    Three of our patients lost 10, one patient <20 and one 24 degrees of preoperative flexion. Average preoperative varus was -19.71 degrees immediate postoperative and 12th week postoperative values angle measured 8.3degrees the carrying angle post operatively was within 4 to 7 degrees of the normal in all our patients.

The lateral condylar prominence index had increased <25% in five patients and no increase in seven patients. In one patient it increased by >25%.  Cosmetically all were satisfied with the outcome. There had been no neurovascular complication, unsightly scar or any residual deformity. Stable fixation had led our most of the cases to achieve >170 degree of supination- pronation. Two patients complained of moderately severe residual pain at the end of 12 weeks post operatively. Our results were as follows as per Bellemore criteria of functional grading

Table 2: Distribution of Study Participants

Grade

No of cases

Percentage

Excellent

10

76.9%

Good

2

15.4%

Poor

1

7.7%

 

 Cosmetically all were satisfied with the outcome. There had been no neurovascular complication, unsightly scar or any residual deformity. Stable fixation had led our most of the cases to achieve >170 degree of supination- pronation. Comparative table for complications produced in different types of fixations recommended by different authors

 

 

 

Studies

Fixation type

Complication

King and Secor(15 cases)  (2)

MOW, Redial clamp and graft

Ulnar palsies (n=3), aneurysm (n=1), Cubitus rectus (n=3), skin slough (n=1)

Rang M(20 cases)( (8)

LCW, K-wires

Varus (6), stiffness (2)

McCoy and Piggot (20 cases)  (9)

LCW, French method

4-neutral, 2-varus, 2-stiffness

Graham et al. (16 cases)

LCW and cast

Varus (n=2)

Oppenhei IM et al. (45 cases)  (10)

LCW and K-wire with screw

Nerve palsies (n=5), infections (n=3), varus (n=12)

Derosa and Graziano11 cases)  (11)

Step cut and screw

Loss of fixation (n=1)

Kannuji et al. (11 cases) (12)

Dome osteotomy and K- wire

Stiffness (n=2)

Uchida et al. (12 cases) (13)

Steop cut and screw

None

Voss and Kasser (34 cases)  (14)

K-wires

Loss of fixation (n=1)

Present study (13 cases)

LCW, screws and steel wires,

SUPERFICIAL SKIN INFECTION IN ONE PATIENT LOSS OF FLEXION OF >23 DEGREES  FROM  PRE OP STATUS

 In a Meta analytic study the results of four osteotomy techniques were published i.e. lateral closing wedge, dome, complex (multiplanar) and distraction osteogenesis. A mean angular correction of 27.6º (18.5° to 37.0°) was achieved across all classes of osteotomy. For overall rate of good to excellent results was 87.8% (95% CI 84.4 to 91.2). No technique was shown to significantly affect the surgical outcome, and the risk of complications across all osteotomy classes was 14.5% (95% CI 10.6 to 18.5). Nerve palsies occurred in 2.53% of cases (95% CI 1.4 to 3.6), although 78.4% were transient. No one technique was found to be statistically safer or more effective than any other (15).

Bellimore et al followed up  16 patients with post traumatic cubitus varus deformity   operated by a supra-condylar lateral closing wedge  osteotomy by the technique of French (1959).13 were reviewed. Ten of these had an excellent result (16) In another study 17 pts were followed up for a mean period of 5 years. The deformity was corrected in all the cases by a lateral closing wedge osteotomy, mean correction being 12.9 degrees of varus, and a mean range of movement of flexion /extension of 135.9 was achieved The authors concluded that the  lateral closing wedge osteotomy is a safe and effective surgical procedure in correcting traumatic cubitus varus deformity in children, which is easy to operate and can be effective in reducing the complications(17)  Outward angulations of the supinated forearm at the extended elbow, the “carrying angle”, is present in utero and is completely developed in the newborn baby (King and Secor 1951)(2). Under normal conditions it is unchanged throughout life and is not altered by secondary sexual development (Steel and Tomlinson 1958) (18). Smith, in 1960, studied 150 normal children and found the average carrying angle to be 6. 1˚ {176} in girls and 5.4˚ {176} in boys. A change in the carrying angle after treatment of a supra-condylar fracture may result from inadequate reduction, from loss of reduction with consequent malunion, or from disturbance of growth (19, 20, 21) Most authors consider that the deformity results from inadequate reduction, leaving a residual rotatory deformity which can collapse into medial or lateral tilt and therefore a varus or valgus deformity. 3, 19, 22, 23 The acceptance of inadequate reduction is partly due to the great difficulty of assessing the clinical carrying angle in the flexed elbow (Bosanquet and Middleton 198324. It is also difficult to obtain adequate anteroposterior radiographs when the elbow in this position

Three types of osteotomy have been described for correction of varus deformity of the elbow a medial opening wedge with bone graft; rotation of an oblique osteotomy; and a lateral closing wedge.

King and Secor (1951)2 reported 15 cases in which a supra-condylar osteotomy was opened medially and held by a tibial bone graft. This method has the great disadvantage that it necessitates anterior transposition of the ulnar nerve. Amspacher and Messenbaugh (1964) 3 reported four cases in which oblique osteotomy corrected varus angulations and rotational deformity simultaneously. This method creates the difficulty of achieving a two-plane correction with a single cut, and means that rotation is needed to correct the varus even though rotational deformity may be minimal.

A lateral closing wedge is the simplest means of correction and some rotation can be added if required.

Holding the correction can be difficult, and several methods have been described. Fixation in a cast with the elbow flexed and the forearm pronated provides an unreliable hold on the distal fragment and significantly increases the risk of ischemia. Rang (1974)8 reported that three of eight patients treated in this way required further correction.  Fixation with Kirschner wires may provide an adequate hold but is associated with complications. Eleven of the 13 children treated with Kirschner wire fixation were reviewed; there had been pin-track infections in four, and three had unsightly scans. Pin loosening, loss of fixation and recurrent deformity occurred in two of the four children with pin-track infection. Rang (1974) treated 20 patients with K-wine fixation and reported quite serious complications: an aneurysm of the brachial artery, infection of bone, nerve palsies, skin loss and loss of fixation. The French technique uses an intact periosteal hinge medially and two screws with a wire loop laterally to stabilize the distal fragment. Bellimore et al (7) followed up 16 patients of post traumatic supra condylar fracture treated by French technique and reported excellent results in 13 patients. Describe Bellemore modification of French

We have operated on 14 patients of post traumatic cubitus varus deformity using a modification of the modified French osteotomy. We have used a lateral incision compared to a posterolateral incision in the modified French osteotomy

We have used a muscle splitting rather than a muscle cutting approach .this we think helps in early rehabilitation

We have used a supine position rather than a prone position as required by the French and modified French techniques. This is less cumbersome in the anesthetist point of view and the correction varus and the rotation deformities are better controlled in supine position. Our results are comparable with 10 out 13 patients giving excellent and 2 giving good results and only 1 patient is assessed to be of poor result.

 

CONCLUSION:

We believe that the modified method of French osteotomy is a simple reliable, acceptable and effective method. By doing the osteotomy through lateral muscle sparing approach, excellent to good results can be obtained.

A statistical analysis is not attempted due to smallness of our series. The present method when followed meticulously can achieve satisfactory results even in the hands of a primary care orthopedic surgeon, in a rural setting with less than ideal working conditions

 

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