All supracondylar osteotomies of the distal aspect of the humerus healed uneventfully by the end of the fourth week, at which time the percutaneous pins were removed. Postoperative radiographs of the elbow demonstrated that the lateral condylar nonuion united within two months in four patients and within three months in the remaining four patients. Elbow range of motion improved progressively until the sixth month postoperatively and then did not improve further.
The clinical and radiographic postoperative follow-up period was a mean of 4.5 years (range, 3.1 to 7.7 years). At the last follow-up evaluation, the total available arc of elbow motion in the flexion-extension plane improved in three patients (Cases 3, 4, and 7), remained unchanged in four patients (Cases 1, 5, 6, and 8), and decreased in one patient (Case 2). The mean total arc of elbow motion was 131° (range, 120° to 145°) preoperatively and 131° (range, 110° to 145°) postoperatively. No loss of elbow motion resulted from the surgical procedure, except in one boy who lost 10° of motion. Three of the four patients who had preoperative elbow pain had complete relief of pain postoperatively. The remaining patient reported that the preoperative pain had decreased. The three patients who had elbow instability preoperatively had no such symptoms at the time of the latest follow-up.
The mean postoperative humerus-ulna angle at the last follow-up examination measured 5.5° (range, 3° to 9°) of valgus. All patients were satisfied with the overall cosmetic outcome of surgery. Muscle weakness was not reported by any patient or observed in any postoperative assessment. According to our modification of the Dhillon scoring system, the result was rated as excellent for two patients (Fig. 3-A, 3-B, 3-C, 3-D), good for four patients, and fair for two patients. No patient subsequently had a recurrent cubitus valgus deformity or had a medial shift of the humerus-ulna axis.
Nonunion of a fracture of the lateral condyle can result in a progressive cubitus valgus deformity5,8 and late ulnarnerve neuropathy5,9,10. Currently, there are several treatment options. For ulnar-nerve neuropathy, anterior transposition of the ulnar nerve is a common procedure11,12. Supracondylar osteotomy of the distal aspect of the humerus is also generally believed to be necessary to relieve the tension on the ulnar nerve when the cubitus valgus deformity is ≥20°11,12. However, treatment of the lateral condylar nonunion is controversial because of the reported high rates of complications1-6. Nonetheless, the advantages of treating the nonunion itself that have been reported include improvement in elbow stability11,12, less elbow pain during sports11,12, and the prevention of further progression of the cubitus valgus deformity and possible tardy ulnar palsy12.
In this study, the main indication for treatment was the progression of the cubitus valgus deformity. We used a domeshaped supracondylar osteotomy of the distal aspect of the humerus to correct the deformity. However, we believe that the deformity would have recurred if the nonunion was not repaired because our patients were all skeletally immature. Therefore, the lateral condylar nonunion was stabilized to prevent recurrence of the deformity. The postoperative cubitus valgus deformity was well corrected and was maintained at a mean follow-up interval of 4.5 years. Additionally, the elbow pain that occurred in four patients was relieved in three patients and was decreased in one. The preoperative elbow instability in three patients was also eliminated. However, it should be stressed that only nonunions without substantial rotation should be treated with this new technique.
Attempted anatomical reduction and rigid fixation of the lateral condyle has frequently resulted in complications including loss of motion3-6, osteonecrosis of the fragment1,3,4, and persistent nonunion6,7. It appears that extensive soft-tissue stripping, undertaken while attempting to mobilize and reduce the fracture fragments anatomically, constitutes the main cause of these complications2,11. As a consequence, several authors have recommended in situ arthrodesis, rather than anatomic reduction, of the nonunited lateral condylar fragment2,11,13. To improve the outcome of cubitus valgus secondary to a lateral condylar nonunion, we developed this new technique. In comparing the new method with traditional surgical procedures, three advantages can be readily identified: the need for only a single posterior midline skin incision, a posterior approach to the lateral condylar nonunion, and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus.
The traditional techniques used to treat a lateral condylar nonunion usually require a medial skin incision for anterior transposition of the ulnar nerve and a separate lateral skin incision for bone-grafting and internal fixation of the lateral condyle and a possible concomitant supracondylar corrective osteotomy12. With two scars, the cosmetic appearance can be compromised particularly because the lateral scar crosses the Langer lines in this area and therefore tends to hypertrophy14,15. We have found that the posterior scar is more acceptable cosmetically. Fewer of these scars become hypertrophic, and the posterior location has led to better patient acceptance16.
For nonrotated and minimally rotated lateral condylar nonunions, the fracture can be readily identified on the anteroposterior radiograph. Therefore, the fracture surfaces can be exposed directly through the posterior approach. If no attempt at anatomical reduction of the lateral condylar fragment is made, extensive soft-tissue stripping can be avoided. Under direct vision, the fibrous tissue embedded in the gap between the fracture fragments can be removed with relative ease17. In our experience, only the fracture surfaces over the metaphysis need to be refreshed and the portion in the physis and epiphysis can essentially remain untouched. As part of this technique, the lateral condyle only needs to be fixed in situ by means of two small cancellous compression screws. In this study, all of the nonunions could be easily compressed and no bone graft was necessary. Because the posterior approach allows direct access to the nonunion site and reduces the amount of soft-tissue dissection necessary to achieve compression, the risk of jeopardizing vascularity of the lateral condyle can be avoided. No osteonecrosis of the lateral condyle occurred in this series.
A closing-wedge osteotomy has been used traditionally to correct the cubitus valgus deformity, although there have been a few associated disadvantages4,12. The most frequently reported disadvantage is the loss of correction4. With lateral condylar nonunion, the lateral side of the distal humeral metaphysis usually is somewhat hypoplastic and there may be lateral instability of the elbow12. In order to stabilize the lateral condyle, a layer of heavy fibrous tissue often develops around the nonunion site. In a varus closing-wedge osteotomy, the lateral fibrous tissue is stretched and creates a large valgus moment on the lateral side of the elbow. This valgus moment renders the osteotomy site unstable and makes it difficult to appropriately fix the site to maintain the achieved correction. The second disadvantage to a closing-wedge osteotomy is the resultant decrease in postoperative elbow range of motion12. With a closing-wedge osteotomy, the soft tissues in the lateral aspect of the elbow tend to be overstretched, thus reducing the range of motion of the elbow. Therefore, posterior capsulotomy and partial lateral triceps tenotomy are frequently necessary in order to improve the postoperative range of motion12. The third disadvantage is the possibility of a secondary elbow deformity developing subsequent to surgery. For the closing-wedge osteotomy, a large triangular bone block usually needs to be removed. This typically results in a large difference in surface areas between proximal and distal fragments at the osteotomy site. After positioning the larger distal fragment against the much smaller proximal fragment, a medial epicondylar prominence often results because of a medial translation of the humerus-ulna axis. The cosmetic outcome of the procedure is compromised because of these anatomical changes. When a dome-shaped osteotomy is used, the rotation center of the distal humeral fragment tends to remain at the midline of the humerus, such that only a small rotation arc is necessary to correct the deformity. A much smaller valgus moment is created, and the round distal fragment is well contained within the dome of the proximal fragment. Therefore, with a dome-shaped osteotomy, mechanical stability at the osteotomy site is enhanced and, as evidenced by the results of our study, loss of correction is unlikely to occur. In addition, rotating the distal humeral fragment with its rotation center located at the midline of the humerus decreases the likelihood that it will shift medially to create a medial epicondylar prominence.
We concluded that, with better exposure of the lateral condylar nonunion through a posterior approach, the nonunion can be stabilized effectively and postoperative loss of motion and osteonecrosis of the lateral condyle can be avoided. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. In carefully selected patients, this new technique can be an effective method for the treatment of this clinically challenging problem.
A table presenting clinical and radiographic details on all patients is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the Department of Orthopaedic Surgery, Kaohsiung Medical College, Kaohsiung City, Taiwan, Republic of China
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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