Osteotomy around elbow

Osteotomies around elbow

1. Osteotomy around elbow Dr Sushil Sharma

2. Introduction Ostetomy around elbow performed commonly for the correction of cubitus varus & cubitus valgus deformity

3. Cubitus Varus Most common cause: Malunited supracondylar fracture Deformity due to Medial tilt/shift Internal rotation Posterior tilt/shift (extension) Rotation and hypertension contribute to the deformity, but varus is the most significant factor Problems Cosmetic deformity Posterolateral rotatory instability Tardy ulnar nerve palsy Predisposed to lateral condyle fracture

4. Osteotomy – Cubitus Varus Three basic types Lateral closing wedge osteotomy Oblique osteotomy with derotation M edial opening wedge osteotomy with a bone graft

5. Pre-requisite for Osteotomy Duration : At least 1 year after the fracture Counselling to the patient regarding the procedure

6. Rules of Osteotomy Center of Rotation of Angulation (CORA)

7. Lateral closing wedge osteotmy Easiest, the safest, and the most stable osteotomy . L ateral closing wedge osteotomy with a medial hinge will correct the varus deformity, with some minor correction of hyperextension Types Lateral closing wedge osteotomy (Voss et al) French osteotomy Modified french osteotomy Different methods of fixation Two screws and a wire attached between them Plate fixation Crossed Kirschner wires Staples

8. French Osteotomy Posterior approach Detach the lateral half of the triceps from its insertion Cortex is broken Medial periosteum left intact Approximate the cut surfaces, and correct the rotation deformity by rotating the distal fragment externally until the distal screw is directly distal to the proximal screw. Approximate the wedge till the 2 screws are parallel Two parallel screws that are attached by a single figure-of-eight wire that is tightened for fixation. Danger of damaging the physis is minimized

9. French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years David North et al. Journal of Pediatric Orthop 2016 The results of the French osteotomy are comparable with the more technically demanding dome, step-cut translation and multiplanar osteotomies , with a lower complication rate.

10. Modified French Osteotomy Bellemore modification FRENCH Modified FRENCH Posterior longitudnal approach Posterolateral Lateral half of triceps detached Whole triceps detached Ulnar nerve explored Ulnar nerve NOT explored Medial cortex broken Medial cortex intact (so more stable)

11. Step Cut Osteotomy ( DeRosa and Graziano ) A modification of lateral closing wedge osteotomy Posterior approach to the distal humerus Place the apex of the template (angle to be corrected) medially Using a template constructed preoperatively, make a lateral closing wedge osteotomy in the metaphyseal region superior to the olecranon fossa . Fixed with single cortical screw

12. Step-cut translation osteotomy and fixation with a Y-shaped humeral plate If a more extensive osteotomy is needed Both cubitus varus & valgus can be corrected Move the lateral edge of the distal fragment into the apex of the proximal osteotomy site, and increase the degree of correction as the apex is moved medially. Corrects deformity only in coronal plane. Fix with Y shaped plate Apply two screws to the medial condyle and three screws to the lateral condyle

13. Oblique Osteotomy with Derotation Aims to correct rotational component but usually not necessary Types Amspacher and Messenbaugh correct a two-plane deformity with one osteotomy Dome osteotomy with derotation (Uchida ) three-dimensional osteotomy Correction of medial tilt, internal rotation & posterior tilt

14. Amspacher and Messenbaugh Expose the elbow posteriorly Expose subperiosteally the supracondylar part of the humerus Oblique osteotomy about 3.8 cm proximal to the distal end of the humerus , directing it from posteriorly above to anteriorly below Tilt and rotate the distal fragment until the internal rotation and cubitus varus have been corrected. With the fragments in proper position, fix them with a screw inserted across the middle of the osteotomy

15. Medial Opening Wedge Osteotomy with bone grafting (King & Secor ) Requires bone grafting Disadvantages Gains length Creates a certain amount of inherent instability. Stretches and damages the ulnar nerve (due to lengthening)

16. Cubitus valgus Causes Non union of lateral condyle fracture proximal migration of the lateral condyle the cartilaginous articular surface of the distal fragment comes in contact with the bony surface of the proximal fragment Malunited supracondylar fracture humerus Osteonecrosis of lateral trochlea Progressive deformity that alters elbow mechanics & causes neurological involvement Effects Tardy ulnar nerve palsy

17. Treatment - Osteotomy Milch devised two osteotomies Milch type I fractures (Salter-Harris type IV) Little lateral displacement when the nonunion is seen relatively early. Cubitus valgus usually is not as marked. Types Closing wedge medial osteotomy (Speed) Opening wedge lateral osteotomy ( Milch ) Combine the osteotomy with an autogenous bone graft and smooth pin fixation to the epiphysis.

18. Milch Opening Wedge Displacement Osteotomy In Milch type II fractures, there is significant lateral displacement of the fragment and some rotation. Posterior muscle-splitting incision Simple transverse osteotomy at the level of the intersection of the forearm axis with the lateral cortex of the humerus Notch the inferior surface of the proximal fragment to receive the apex of the superior surface of the distal fragment, which is moved laterally Adduct the distal fragment until the excessive angle of abduction ( valgus ) has been reduced to the normal carrying angle

19. Step-Cut Translation Osteotomy with a Y-Shaped Humeral Plate (Kim et al) For severe deformity and extensive correction Uniplanar osteotomy that corrects deformities only in the coronal plane Posterior approach Dissect the soft tissue, and expose the ulnar nerve. In patients with ulnar nerve palsy, perform an anterior subcutaneous transposition of the nerve Perform the initial osteotomy 0.5 cm superior to the olecranon fossa , perpendicular to the axis of the humeral shaft Move the medial edge of the distal fragment into the apex of the proximal osteotomy site. The degree of correction increases as the apex is moved laterally Fixation with Y-shaped stainless steel plate. Apply three screws to the medial condyle and two screws to the lateral condyle In patients with cubitus valgus arising from nonunion of the lateral condyle , remove impinging hypertrophic fibrous tissue followed by decortication of the bone and the addition of a wedge-shaped graft.

20. Complications Stiffness Persistence of deformity Over correction Under correction Myositis ossificans Loss of fixation Neurovascular injury

21. Thank You