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Khujanazarov Ilkhom Eshkulovich MD, Scientific Research Institute Traumatology and Orthopedics, Tashkent Medical Academy, Republic of Uzbekistan E-mail: [email protected]
Surgical treatment of pseudoarthrosis of lateral humeral condyle of humerus with cubitus valgus in children
Abstract: Object of the research work was 59 patients with lateral humeral condyle pseudoarthrosis with or without cubitus valgus, whom three types of surgical correction are spent depending on weight of deformation, prescription of the got trauma and age of the patients. Pseudoarthrosis liquidation or necrosis field resection are made in 21 patients, for 8 patients are admitted the extraarticular supracondylar osteotomy of humerus with ulnar nerve transposition and stabilization by Ilizarov's apparatus and other 30 patients was corrected by the developing own clinic technique — «Lateral humeral condyle pseudoarthrosis resection of the humerus, supracondylar osteotomy of humerus and osteosynthesis by Ilizarov's apparatus». These differential techniques help to shape the distal part of humerus, thus, restoring the function of the elbow joint. Keywords: lateral humeral condyle, pseudoarthrosis, children, osteotomy.
Introduction
Damages of bone structures of an elbow joint in children, according to various researchers [1; 2; 3; 4; 5], averaged from 16 to 40 % among several kinds of bone fractures and 50-80 % fromall intraar-ticulate damages ofupper extremity. The lateral condyle of humerus is one of basic elements of the distal end of humerus, which is made role as a lateralsupporting point and participates in correct distribution of attaching loading on elbow joint and participates in rotation of forearm bones [4; 5; 8]. Nonunion of the lateral humeralcondyle in time leads to aseptic necrosis of lateral part of distal end of humerus with loosening of its articulate structures. Frequently the part of the block of humerus is resolved. The absence of lateral supporting point leads to aggravation of cubitus valgus with following of consequences [6; 7; 8; 9; 10]. Today this pathology becomes a social and economic problem so children with pathology become persistent invalids.
Purpose was to develop the differentiated approaches for lateral condyle of humerus pseudoarthrosis surgery with cubitus val-gus in children.
Materials and methods
Forobservation underwent 59 children, which are treated since1998 to 2013 yy in Children's Traumatology Department of Research Institute of Traumatology and Orthopedics of Ministry of Health ofRepublic of Uzbekistan with lateral condyle
pseudoarthrosis of humerus with cubitus valgus. For all patientsclin-ic-laboratory analyses, radiologicalmeasurement, a tomography investigation and electromyography of damaged segment are carried out in dynamics in comparison by healthy extremity.
Due toclinic-radiological changes the electronic software productwas developed, that allowsobserving the severityof elbow joint valgus deformity in patients with lateral condyle pseudoarthrosis of humerus, which data are presented in table 1. This developed software product is registered and patented № DGU 01354 in Patent Office Republic of Uzbekistan.
Results and discussions
Distribution of patients who have admitted on treatment with lateral condyle pseudoarthrosis of humerus (after trauma — more than 4 months) due to on age and genderwas made, that presented in table 2. The age of patients fluctuated from 2 till 18.
As follows from presented data in table 1, all patients have been distributed on 5 age groups: 3-7 years — 13 patients (9 boys and 4 girls); 7-11 y. — 17 (10 — boys and 7 girls); 11-15 y. — 25 (18 boys, 7 girls) and adolescent group from 15 till 18 y. — 4 patients.
As has shown the retrospective analysis data, causes ofnonunion occurrence were untimely diagnostics or wrong interpretation of data, omissions duringchoice of treatment tactics and to decrease ofrespon-sibility, infringement of an orthopedic regimen, especially by boys.
Table 1. - Distribution of patients by lateral condyle pseudoarthrosis of humerus due to an age, sex, severity level of deformation and operation types (n = 59)
Lateral condyle pseudoarthrosis of humerus with elbow joint valgusal deformity
Age Gender I operation type (n = 21) II operation type (n = 9) III operation type (n = 29) Total
Degree of deformity Degree of deformity Degree of deformity
I II III I II III I II III
3-7 b 3 2 - - - - - 3 1 9
g 4 - - - - - - - - 4
7-11 b 3 1 - - 2 1 - 2 1 10
g - 1 - - - - - 2 4 7
11-15 b 1 2 3 - 1 2 1 5 3 18
g - 1 - - - 2 - 1 3 7
15-18 b - - - - - 1 - 1 2 4
g - - - - - - - - - -
Total 11 7 3 - 3 6 1 14 14 59
Inall patients the correction methods were chosen on three types of operation techniques due to severity level of deformation of elbow joint, prescription of the got trauma and age of the patients.
The first operation type is spent in 21 (35.6 %) patients with lateral condyle pseudoarthrosis of humerus without cubitus valgus deformation (15 boys, 6 girls) who complicated with elbow joint contracture various severity. From them in 12 cases 1st severity level of deformation, in 5 children — 2nd severity level and other 3 patients with 3rd severity level of deformation were marked. In all these patients it is spent elbow joint arthrolysis with elimination ofcapitellum pseudoarthrosis and stably functional osteosynthesis with Ilizarov's device consisting of 2 semicircles. The operation feature was that the adjacent bone fragments surfaces covered with a fibrous tissue "were freshened" to a healthy bone tissue. In a maternal bed was created a surface corresponding to fragment ofcapitellum and made its adaptation. Its mobilization was made for the best adaptation of capitellum from the adhesive secondary healing (scar) tissues then bone fragment adapted and was made reduction for a maternal bed. A following stage was conducting three bulb-tipped pins in diameter of 1.5 mm. through capitellum: the first — in a diagonal direction on the outside to inside and from below-upwards, the second — it is perpendicular to a humeral bone axis on the outside to inside. The third pin spent through the lower third of humeral bone axis, thus the bulb-tipped pinlocated opposite concerning the previous pins for creation of an opposite directioncompression. Then Ilizarov's apparatus installation carried out from 2 semicircleswith creation of stability bone fragments by pins tension and postoperative wound took in hermetically.
The second operation type is spent in 9 (15.3 %) patients (7 boys, 2 girls). On deformation severity level was marked the 2nd severity level in two cases and in 6 cases the 3rd severity level. In these patients it is spent the extraarticular varusal correction osteotomy of humerus with an elbow nerve transposition and Ilizarov's apparatus imposing. It is necessary to notice, that the currentopera-tion type was made in children of an average and the senior school age. This results from the fact that often patient addressed for the help very much late in connection with development peripheral neurotrophic infringements and hypotrophy development corresponding hand and forearm muscles up to their atrophy, because of cubitus valgus progressing. With the times occurs almost full distal end resorption of humerus with adapted lateral condyle pseudoarthrosis formation. In such cases in patients the full volume of elbow joint movement was marked and we in this group of patients spent only correction of cubitus valgus with an elbow nerve transposition and an osteosynthesis with Ilizarov's device.
Carrying out for children of the senior age groups intra-and extraarticular reconstructive operations significantly raises the risk of development of stable elbow joint contracture, which are very difficultly giving in working out demanding long time (3-3.5 years), a regularity of performance of physio-functional procedures and exercises and patience as parents, and patients.
Last year we were limited to carrying out of extraarticular corrections with an elbow nerve transposition without intraarticu-late intervention as some parents negatively concern for postoperative contracture, demanding long time for working out of available deficiency of joint movement volume.
The third operation type is made in 29 (49.1 %) children (19 boys, 10 girls) mainly with 2nd and 3rd severity level of cubitus valgus deformations. In 3 cases children had 1st severity deformation level, in 14-2nd severity level and in 13 cases 3rd severity deformation level. These patients had rough anatomic elements defect of distal parts of humerus because of aseptic necrosis of the lateral condyle and parts of internalblock with the subsequent of neurotrophic disorders.
We in such difficult cases had been developed a new technique repair of lateral condyle pseudoarthrosis of humerus with cubitus valgus, consisting in a pseudoarthrosis resection of with the supracondylar extraaticular corrected osteotomy of humerus, n. ulnaris nerve transposition and cross fixing of bone fragments and stable-functional osteosynthesis by Ilizarov's apparatus, consisting of 2 semicircles on which was received the certificate of receipt from 23.02.05. №IAP0060 Patent Office of Republic of Uzbekistan. The essence of method consists in the maximum preservation of the soft tissue cover of lateral lateral condyle elements and capitellum of humerus as blood supply source, n. ulnaris transposition, correcting osteotomy distal part of humerus, and fixation of bone fragments and "T" shape transposition all of elements, to cross fixing withwires, the installation of Ilizarov's apparatus consisting of 2 semicircles. Fixation duration of the apparatus at this technique depended on degree of bone elements consolidation which corresponded to 5-8 weeks.
It is necessary to notice, that after carrying out of this difficult intra-and extraarticular elbow joint reconstructive operation, first of all the upper extremity axis was corrected, but after device removal it is necessary the period of 2-2.5 years for full restoration of elbow joint functions depending on age of the child and aseptic necrosis processes of the distal end of humerus, as the patient is more younger more full and earlier is restored and formed of joint congruity of distal end of humerus and faster there is a full elbow
joint movements volume restoration. The first received results after such reconstructive operation have shown gradual formation of distal end elements of humerus within 2-3 years. This type of operation is recommended to carrying out for patients are aged till 12 years. The example from our experience is shown.
Clinical example
PatientM., 10 years (disease history № 5422). From his anamnesis: the patient was injured 2 years ago before arrival to RITO clinicin 2010, first time was treated domiciliary by a plaster bandage. During examination a cubitus valgus deformation and upper extremity weakness were defined. During inspection locality cubitus valgus with deformation angle is 32°, flexion — 45°, extension — 180° were defined, the volume of elbow joint movement is made 135°. Marx's line and Gunter triangle have been considerably changed. Fingers movement and sensitivity are kept. The peripheral neurotrophic changes aren't revealed. On the basis
of clinical and instrumentation investigations the diagnosis has been established: Posttraumatic left sided cubitus valgus, the capitellum pseudoarthrosis of left humerus (Fig. 1. a, b, c). In November 2010 the operation № 237-238 «The liquidation of the capitellum pseudoarthrosis of humerus, supracondylar extraarticular correcting osteotomy of humerus with an elbow joint transposition, cross fixing Ilizarov's wires and a stable-functional osthesynthesis using Ilizarov's apparatus from 2 semicircles» (Fig. 1 d, e) are made. The postoperative period proceeded smoothly. Patient has received the corresponding medication, physiotherapeutic therapy. The postoperative wound has begun to live a primary tension. The patient is discharged from the hospital in 9 days in a satisfactory condition. In analysis of the nearest and remote postoperative results the full capitellum consolidation of humerus with distal end anatomical formation humerus are revealed (Fig. 1. f, g, i, h, j, k). In 3 years restoration of full volume of elbow joint movements (Fig. 1.1, m, n, o) was defined.
Fig. 1.
We study the remote postoperative results in terms till 10 years (table 2). For objective estimation of operative results and standardization of studying of the clinic-radiological founding, which defining the pathology necessary for comparison of treatment outcomes between literature data was applied the developed Yu. P. Soldatov and V. D. Makushin (1997) table with indicators of anatomic-functional signs of disease and an estimation of each sign in points: 14-21 — good result, 8-13 — satisfactory, 0-7 — unsatisfactory.
Table 2. - Outcome results
According to the table data in 59 patients the outcome results in 48 (81.3 %) cases were marked as good, in 9 (15.3 %) — satisfied, in 2 (3.4 %) — the unsatisfiedresult, so, preoperatively in this 18-year-old young man with a primary trauma of 12-year-old prescription the hypertrophy of a radius head was marked, postoperatively elbow joint flexion-extension contracture has developed-because of an orthopedic mode infringement and default of the appointed physio-functional purposes. of treatment of patients
Age Sex Lateral condyle pseudoarthrosis of humerus with cubitus valgus Total
I type (n = 21) II type (n = 9) III type (n = 29)
good Satisf unsatisfied good Satisf unsatisfied good Satisf unsatisfied
0-3 b - - - - - - - - - -
g - - - - - - - - - -
3-7 b 4 1 - - - - 2 1 1 9
g 4 - - - - - - - - 4
7-11 b 4 - - 2 1 - 2 1 - 10
g 1 - - - - - 5 1 - 7
11-15 b 6 - - 2 1 - 7 1 1 18
g 1 - - 1 1 - 3 1 - 7
15-18 b - - - 1 - - 3 - - 4
g - - - - - - - - - -
Total 20 1 0 6 3 0 22 5 2 59
As shown by data 2nd table, that, good resultsconsiderably have been received in patients, whom were performed 1 and 3 type operative techniques. Because1 type operation was made in patients with little anatomical and functinal disfiguring of elbow joint and and without joint incompetence and with other side applied method for these patients was sufficient for joint malfunctionrecovery. Third type operation technique was traumatically, but due to the extend joint disfiguring and considerably distal joint elements dislocation that, it was necessary to apply such technique for repair as "T" shape reconstruction of distal part of humerus and fixation by Ilizarov's apparatus, that was reasonable method for correcting.
As has shown the retrospective analysis data, causes of nonunion occurrence were untimely diagnostics or wrong interpretation of data, omissions duringchoice of treatment tactics and to decrease of responsibility, infringement of an orthopedic regimen, especially inboys.
Inall patients the correction methods were chosen on three types of operation techniques due to severity level of deformation of elbow joint, prescription of the got trauma and age of the patients.
Thus, the lateral condyle pseudoarthrosis of humerus with the expressed aseptic necrosis of distal end anatomic structures of
humerus only by operative treatment can prevent the heavy and great complications development in children (progressing cubitus valgus, late period an elbow nerve neuritis and others). Operative intervention should be to as much as possible sparing and differentiated approaches. For capitellum fragment allocation from adhesion it is necessary to aspire to keep communication of a fragment with tendomuscular supplied. Bone fragment fixing should be carried out by external fixing devices with preservation of an elbow joint function, the external immobilization is necessary for occurrence of full consolidation (6 weeks).
Conclusions
1. The lateral condyle pseudoarthrosis ofhumerus is an elbow joint composite pathology, which is met rather often and lead to early physical disability of children.
2. The differentiated tactical approach for a choice of operation type, considering deformation severity level, prescription of injury and age of the child allow improving the treatment results.
3. Developed and approved in our clinic the new surgical treatment technique allows to reach in one stage restoration of anatomy and promotes distal end of humerus formation and by that restores function of an elbow joint in children.
References:
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2. Dorochin A. I. Diagnostic and principles of the treatment of complicated by the delayed union fractures in children. Actual problems of children traumatology and orthopedics. - S. Petersburg, 2004.
3. Kazuhiro M., Hideo K., Hidenko K. et al. Osteosynthesis for old, established non-union of the lateral condyle of the humerus// J Bone Joint Surg. - 1990. - 72.
4. Koh Kh., Seo S. W., Kim K. M. et al. Clinical and radiographic results of lateral condylar fracture of distal humerus in children// J Pediatr Orthop. - 2010. - 5.
5. Kozo Sh., Kazuhiro M., Koichi T. et al. Osteosynthesis for the treatment of non-union of the lateral humeral condyle in children// J Bone Joint Surg.- 1997. - 79.
6. Merkulov V. N., Bagomedov G. G., Krupatkin A. I. Capitellum fractures of humerus and their consequences in children and adolescents. Diagnostic and treatment techniques. - Ryazan, 2010.
7. Merkulov V. N., Stujina V. T., Dorochin A. I. Diagnostic and complex treatment of posttraumatic pseudoarthrosis and defects of long tubular bones in children. Manual for doctors. - CITO named after N. N. Priorova, 2006. - 23.
Differentiated surgical tactics of the posttraumatic "complicated" cubitus varus in children
8. Toh S., Tsubo K., Nishikawa S. et al. Osteosynthesis for nonunion of the lateral humeral condyle//Clinical Orthopaedics and Related Research. - 2002. - 405.
9. Yang J., He T., Liu S. Lateral closing wedge osteotomy for treatment of traumatic cubitus varus deformity in children//Zhongguo xiu fu chong jian wai ke za zhi (Chinese journal of reparative and reconstructive surgery). - 2012. - 6.
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Khujanazarov Ilkhom Eshkulovich MD, Scientific Research Institute Traumatology and Orthopedics, Tashkent Medical Academy, Republic of Uzbekistan E-mail: [email protected]
Differentiated surgical tactics of the posttraumatic "complicated" cubitus varus in children
Abstract: Since 1998 to 2013 we have treated 222 children and teenagers at the Department of Children's Traumatology of Scientific Research Institute of Traumatology and Orthopedics under the Ministry of Health of the Republic of Uzbekistan with "complicated" varus deformations of elbow joint by application of the different types of osteotomy. For all children we observed a good function of the elbow joint with full range of motions. Our fixation method with the use of the Kirschner's wire and Ilizarov's apparatus with 2 rings was modified in order to increase stability and functionality of osteosynthesis. It gives the opportunity of anatomic functional recovery under correction of the varus deformation of the elbow joint of the children.
Keywords: cubitus varus, complication, children, osteotomy.
Introduction
Posttraumatic elbow joint deformation is the most widespread complication appearing after the transcondylar and supracondylar fractures of the children's humerus [1; 2].
The analysis of existing literature demonstrates the poor awareness on the high relevance of complicated varus deformations of the elbow joint accompanied with the elbow joint contracture, "supracondylar" syndrome and peripheral neurovascular modifications. Their treatment result is often unsatisfactory since correction is either insufficient or absolutely lost. Up to now there is no common view on the terms and size of correcting osteotomy in case of varus deformation posttraumatic with "supracondylar" syndrome of the children's and teenagers' elbow joint requiring surgical correction [2; 3].
Deformation is often limiting the elbow joint motions, but parents and children are frequently complaining only about cosmetic defect. Several types of surgical techniques, including wedge, rhomboid, trapezoid, dome-shaped and the other types of osteotomy have been described. A number of bone-holding units, including wires, bows, bolts, sheets, strands and allochtronic units ofvarious designs have been applied [3; 4; 5].
Improvement of the results of posttraumatic varus deformations of the children's and teenagers' elbow joint through application of the cutting-edge research methods and development of differential approach to the surgical treatment is the purpose of our study.
Materials and methods
Since 1998 no 2011 we have treated 222 children with the varus deformation of elbow joint with application of the various types of osteotomy.
All visiting children with posttraumatic varus deformation of the elbow joint passed through the clinical, X-ray, densitometric, ultrasound (US), computer tomography (CT), MRT and functional methods of examination.
We used measuring the physiologic valgus axis on unaffected limb and the varus deformation of the elbow joint on deformed upper limb. Physiologic valgus on unaffected limb was considered as
the "positive" (+) and pathological varus deformation of the elbow joint — as the "negative" (-) one. Required extent of correction was calculated through summation of valgus angulation of unaffected side with the varus angulation of deformed side. We called this angle as the "angle difference" between unaffected and deformed upper limb. The angle difference is very important in correction of deformed limb, in particular, in evaluation of the late fate and comparison with unaffected limb.
Moreover, we suggested the term "supracondylar syndrome". In case of the varus deformation of the elbow joint the "supracondylar syndrome" means the following. In case of high-grade (over 30 °) and complicated children's varus deformations of the elbow joint, the highly emerging and deformed lateral epicondy-lus of humerus and local osteoporosis in external epicondylus of humerus are identified and clinically it is evident as abnormality caused by the tension of lateral collateral ligament of the elbow joint. We called this combination of symptoms as the very "supracondylar syndrome". We have not found this symptom in domestic and foreign literature. Along with that, it is very important in surgical correction of this abnormality.
Besides, the varus deformation with flexion or extensive elbow joint contractures were found in the course of our study due to the anticurve or recurve deformation of the humerus distal edge. In such cases, specifically in case of recurve deformation of the humerus distal edge, first of all, the joint hyperextension appears, and later on — its instability. We had called the combination of these symptoms as "complicated" elbow joint varus deformation and our studies were also devoted to this abnormality.
The number of results of the X-ray examination of this cohort of patients was analyzed for identification of the reason of this syndrome.
We have developed and suggested evaluation criteria for the severity of the posttraumatic elbow joint varus deformation depending on deformation angle and clinical signs of the elbow joint deformation (The patent of RUz: DGU 01287 from 2007).
We used the new type of supracondylar correction osteotomy for correction of "supracondylar syndrome" in elbow joint varus
