An Experience With Dome Osteotomy. Final Copy (123224)
An Experience With Dome Osteotomy. Final Copy (123224)
An Experience With Dome Osteotomy. Final Copy (123224)
varus deformity.
between 7 to 11 years of age. Of these patients 9 were boys and 5 were girls. This
retrospective study was carried out at Combined Military Hospital Abbottabad from
Jan 2011 to June 2012. All patients were followed up 01 year. The main criterion
against which the outcomes were assessed included the range of motion of their
elbow joint, degree of correction of carrying angle and lateral condylar prominence
index.
Results: In light of the assessment criterion the outcome was found to be excellent
in 11 cases and good in 03 patients. Clinical and radiological bone union was
achieved in all cases at 10 weeks. Few complications seen included painful scar
formation, ulnar neurapraxia and pin tract infection. No patient developed lateral
supracondylar part of humerus. 1. It is very unpleasant and generates great anxiety. Most
cases therefore report for surgical correction of this deformity 2. Many corrective
osteotomies have evolved and have been practiced to deal with this pediatric deformity.
However after performing a corrective closing lateral wedge osteotomy it was noticed
that the lateral condyle of the humerus became unduly prominent 3. Multi-centric studies
10.11,12,
were done in this context and nearly all concluded that this end-op cosmetic
appearance was difficult to avoid with the technique of humeral supracondylar lateral
closing wedge osteotomy as the residual distal piece of the humerus inclines laterally in
varus was the primary reason of surgery in all the patients hence the lateral closing
5
wedge osteotomy seemingly failed to obtain the desired cosmetic outcomes .
Resultantly a novel surgical technique was introduced which successfully produced the
a dome osteotomy in the deformed distal humeral metaphysis and then moving the
distal fragment in a lateral arc in line with the already calculated angle of correction.
This re-established a normal carrying angle without creating any resultant bump of the
Methods
09 boys and 5 girls between 7 to 11 years age. This retrospective study was conducted
at Combined Military Hospital Abbottabad from Jan 2011 to June 2012. Patients
included in the series had cubitus varus deformity (10 Left: 4 Right) due to mal treated
were taken the carrying angles were measured. Mean deformity was found to be 7
was performed in all cases with cubitus varus deformity according to the technique
described by Tachdjian. Campbell exposure of distal humerus was done. The midline
axis of the elbow and the superior border of the olecranon fossa (point 0) were marked
as the dome center. The 0A segment was considered the base and a line (0B) was
drawn from point 0 to form the calculated angle of correction (a). The segment 0B
formed the radius of the dome, and the required dome was marked with diathermy.
Point B played the starting point of the osteotomy, and a dome was drawn with 0B as
the radius of the arc (Fig .2). After osteotomy the distal fragment was rotated to point A
and fixed with two 2mm Kirschner wires. An augmentative above elbow Plaster of Paris
posterior slab given in 90 degrees elbow flexion for 3 weeks followed by active
movements of the elbow were progressively started. After 1-1.5 months the wires were
removed.
lateral condylar prominence, final cosmetic appearance, and resultant range of motion.
Results
The patients were evaluated before operation and their range of motion was analyzed
two), and one had an extension of 04 degrees. There was improvement in range of
motion after surgery. The extension range was decreased from 10 to 5 0 in 03 patients.
Two boys and one-girl patients developed certain loss of elbow flexion after surgery
(range 5-150, average 6.60). Union was observed at the end of 10 weeks and there was
The appearance of elbow after dome osteotomy was excellent in 11 patients and good
male & 1 female), which was controlled with oral antibiotics. Two patients developed
hypertrophic scar (2F). One patient (F) had pain in the scar and one patient (M)
Discussion
Fracture in the supracondylar region of humerus is seen commonly in between the ages
reported incidence of cubitus varus is in between 4% to 21% 10. Many late sequelae
associated with distal humeral fractures are ulnar neuropathy, avascular necrosis of the
distal humeral epiphysis11, secondary distal humeral or lateral condylar fracture 12,
however most patients present with the complaint of an unsightly cubitus varus rather
In order to correct the cubitus varus various corrective procedures like medial opening
wedge osteotomy15 , arc osteotomy10 , lateral closing-wedge osteotomy 14, and dome
osteotomy,16, have been performed. The most commonly used procedure to correct the
deformity was seen to be the lateral closing-wedge osteotomy of distal humerus 12.
However after this osteotomy it falsely appeared as if the varus deformity still exists
because of the resultant lateral condylar prominence, because when evaluated for this
appearance with radiographs the measured angle formed by the humeral and ulnar
radical shift in the distal fragment of the humerus, relative to the proximal humeral shaft,
16, 17
thereby causing a protrusion of the lateral humeral condyle. . Excision of the wedge
from lateral distal humerus effectively produced two fragments of unequal width and
hence closing the osteotomy compromised the final cosmetic outcome. . 9, 12, 15.In order to
overcome this disappointing outcome Tachdjian 13 carried out dome osteotomy for
6
correction of cubitus varus, reproduced also in series of Kanaujia et al and Tien et al 7.
In dome osteotomy the center of rotation of the distal fragment was taken as the midline
of the humerus and therefore the varus forces acting at the osteotomy site were much
less and made the osteotomy mechanically more stable. In essence Dome osteotomy
uses the center of humeral mechanical axis as the rotation center thereby preventing
the para midline shift of lateral condyle and thereby preventing it from becoming
CONCLUSION
1. Bellmore MC, Barrett IR, Middleton RWD, et al. Supracondylar osteotomy of the
humerus with correction of cubitus varus. J Bone Joint Surg [Br]. 1984; 66:566-
572.
2. Basilicas TA, Kakos JM, Saige FE, et al. Supracondylar humeral osteotomy in
children with severe posttraumatic cubitus varus deformity. Acta Orthop Belg.
1999; 65:65-71.
3. Devnani AS. Lateral closing wedge osteotomy of humerus for post- traumatic
4. French PR. Varus deformity of the elbow following supracondylar fractures of the
5. McCoy GF, Piggott J. Supracondylar osteotomy for cubitus varus. The value of
7. Tien YC, Chih HW, Lin GT, et al. Dome corrective osteotomy for cubitus varus
8. Ali AM, Abouelnas BA, Elgohary HS. Dome osteotomy using the paratricipital
2014; 139(6):613-20.
10. Matsushita T, Nagano A. Arc osteotomy of the humerus to correct cubitus varus.
11. Abbott MD, Buchler L, Loder RT, Caltoum CB. Gartland type III supracondylar
13. Tachdjian MR. Osteotomy of distal humerus for correction of cubitus varus. In:
1591.
14. Yang J1, He T, Liu S, Peng M, Liu M. Lateral closing wedge osteotomy for
15. Solfelt DA1, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the
16. Pankaj A1, Dua A, Malhotra R, Bhan S. Dome osteotomy for posttraumatic