Suracondylar Dome Osteotomy For Cubitus Valgus Deformity Associated with A Lateral Condylar Nonunion in Children

Author(s): Tien YC, Chen JC, Fu YC, Chih TT, Hunag PJ, Wang GJ

Source: JBJS 87:1456-1463, 2005.

Summary:

This article reviews the treatment of lateral condyle nonunions in skeletally immature patients with cubitus valgus deformity greater than 20 degrees.  Eight patients underwent a supracondylar dome osteotomy with fixation of the lateral condylar nonunion with 2 small screws without bone grafting or takedown of the nonunion site.  A posterior approach allowed for fixation of the lateral condyle through a window on the lateral aspect of the triceps, followed by the dome osteotomy through a central split in the triceps as well as ulnar nerve anterior transposition via a medial dissection.  The mean age at the time of the lateral condylar fracture was 3.7 years and the mean age at the operative intervention was 8.6 years with a mean interval between the fracture and the procedure being 5 years.  The clinical and radiographic postoperative follow-up period averaged 4.5 years.  Four patients reported preoperative elbow pain which was relieved in 3 patients and improved in 1 patient.  Three children reported a “giving way” sensation which resolved in all patients.  The preoperative elbow range of motion was normal in 4 patients and 3 patients had a elbow flexion contracture that ranged from 10 to 15 degrees and 2 patients had 10 to 15 degrees loss of full flexion.  The total elbow arc of elbow motion improved in 3 patients, remained unchanged in 4 patients and decreased in 1 patient.  The mean total arc of elbow motion was 131 degrees (range, 120 to 145) preoperatively and 131 degrees (range, 110 degrees to 145 degrees) postoperatively.  Only 1 child lost 10 degrees of motion.  All supracondylar osteotomies of the distal aspect of the humerus healed uneventfully by the end of week 4 at which time the percutaneous pins were removed.  The lateral condylar nonunions united within 2 months in 4 patients and within 3 months in the remaining 4 patients.  The mean preoperative humerus-ulna angle was 31 degrees (range, 24 degrees to 36 degrees) which improved to 5.5 degrees (range, 3 degrees to 9 degrees) of valgus.  All patients were satisfied with the overall cosmetic outcome of the surgery and there were no intraoperative or postoperative complications.  According to a modified Dhillon scoring system, the result was rated as excellent for 2 patients, good for 4 patients and fair for 2 patients.  There was no reported recurrence of cubitus valgus deformity.

The treatment for lateral condyle nonunions in skeletally immature patients with significant cubitus valgus has been controversial with notable associated complications including persistent nonunion, avascular necrosis of the lateral condyle, and tardi ulnar nerve palsy.  This study reports a single operative approach to repair the nonunion, restore alignment and prevent ulnar nerve dysfunction via a posterior approach with minimal dissection of the condyle to prevent avascular necrosis and a dome osteotomy to minimize deformity following the corrective osteotomy.  Overall, there were excellent results with no persistent nonunions, no recurrences of the deformity, restoration of  alignment and cosmesis.  The authors provide a fairly detailed approach to restoring overall alignment which is best visualized via their diagrams.  The posterior approach allows for better exposure with identification of anatomic landmarks for more precise cuts and restoration of alignment.

 
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