Original Article

MODIFIED FRENCH OSTEOTOMY

FOR CUBITUS VARUS DEFORMITY

ISRAR AHMAD, ALAMZEB KHAN*, MOHAMMAD IDREES

Department of Orthopaedics & Trauma, Khyber Teaching Hospital, Peshawar
Agency Headquarter Hospital, Miranshah, North Waziristan*

ABSTRACT
Objective: To evaluate the outcome of Modified French Osteotomy for correction of cubitus varus deformity.
Design & Duration: Descriptive quasi-experimental study from Feb. 2000 to Oct. 2003.
Setting: Dept. of Orthopaedics and Trauma, Post-Graduate Medical Institute, Hayatabad Medical Complex, Peshawar.
Patients: All children, aged 3-12 years, with cubitus varus deformity were included in the study.
Methodology: Pre-operative clinical as well as radiological assessment of upper extremities were done in all cases.
Modified French osteotomy was done to correct the deformity. All patients were followed for seven months. Physical
examination for the range of motion, scar and post-operative complications were assessed. Antero-posterior and
lateral radiographs of the elbow were obtained, and the carrying angles and lateral condylar prominence index were
measured and recorded.
Results: Out of the total 30 patients, 26 were male and four female. Left side was involved in 24 cases and the right
side in six. The average age at the time of osteotomy was seven years (range 3½-12 years). The average pre-operative
carrying angle was 25.2o (range 18-30o) and the post-operative angle 8.7o (range 5-13o valgus). The average pre-
operative range of motion was 122.6o (range 105-135o) and the post-operative range 123.86o (range 90-135o). The
average pre-operative lateral condylar prominence index (LCPI) was 175.56 (range 128-232) and the post-operative
lateral condylar prominence 156 (range 100-240). Based on Bellmore criteria, 25 patients showed excellent, three
good and two a poor result.
Conclusions: Modified French technique of supracondylar osteotomy has excellent results in the management of
cubitus varus in terms of cosmesis, radiological findings and fewer complications.

KEY WORDS: Deformity, Trauma, Cubitus Varus, French Modified Osteotomy

INTRODUCTION only a cosmetic deformity8-10, though recent studies

have suggested that there may be associated morbidity
Cubitus varus is a common long term complication of also4,8. An increased incidence of lateral condylar fractu-
supracondylar fracture malunion resulting in medial res in the elbow in varus4,11,12 is associated with dislo-
displacement, internal rotation and extension of distal cation of both the medial portion of the triceps and the
fragment; this then permits the distal fragment to tilt ulnar nerve8, 13. In addition to the snapping it may cause
into varus1-5. Cubitus varus produces a cosmetic defor- medial elbow pain14-16. Cubitus varus shifts the line of
mity, besides a defect in the function of elbow3,6,7. Varus pull of the triceps more medially, which can cause ante-
deformity has been considered by many authors to be romedial displacement of the medial portion of triceps
during elbow flexion. The ulnar nerve is concomitantly
pushed or pulled anteromedially by the triceps, thus re-
sulting in ulnar neuropathy from friction neuritis or dy-
namic compression by the triceps against the epicon-
Correspondence: dyle13. Cubitus varus can also be associated with poste-
Dr. Israr Ahmad, Senior Registrar, rior instability of the shoulder17.
Department of Accident & Emergency/Orthopaedics,
Khyber Teaching Hospital, Peshawar. Cubitus varus may be associated with recurrent posterior
Phones: 091-7109446, 0300-5948476. dislocation of the head of the radius14,18. The varus de-
E-mail: [email protected] formity changes the biomechanics of the elbow, which

270 Volume 23, Issue 4, 2007

 Modified French Osteotomy for Cubitus Varus deformity I. Ahmad, A. Khan, M. Idrees

may lead to posterolateral rotatory instability of the some cases where additional rotational deformity was
elbow12,14. identified, then correction was attempted by placing the
screws in different positions in the sagittal plane. The
Understanding the biomechanical forces of this combin- wedge was cut with an oscillating saw, leaving the me-
ation of deformities will guide treatment rationale in dial cortex intact to be cracked as a hinge, thereby ap-
the future. Cubitus varus deformity secondary to distal proximating the screws. The screws were then wired
humeral malunion is not necessarily a benign condition, together in a figure of eight fashion and the wound clo-
and may have significant long term implications relating sed. Post-operatively, the elbow was placed in 90o flex-
to elbow instability, medial elbow pain from subluxation ion with the forearm in neutral position in a long arm
of the medial head of the triceps over the epicondyle, back slab for three weeks, after which mobilization was
and ulnar neuritis or neuropathy. Preventive corrective started.
osteotomy is an intervention that may merit conside-
ration19-23. Follow-up Assessments
All the patients were asked to return to the hospital for
This study was designed to evaluate the outcome of clinical and radiological evaluations for a period of se-
French modified osteotomy for cubitus varus deformity. ven months. Physical examination included assessment
The study carries great significance as it evaluates the of the scar, carrying angle and ROM. X-rays of elbow
outcome of a commonly performed procedure for a in anteroposterior and lateral views were taken and the
common deformity. carrying angle measured. Carrying angle, lateral condylar
prominence index and range of motion were used as
PATIENTS & METHODS strict criteria to categorize the results (Table I).

Supracondylar humeral osteotomy by Modified French RESULTS

technique was performed on 30 children, aged 3 to 12
years, for post-traumatic cubitus varus deformity, bet- Out of the total 30 children, 26 were male and the rest
ween February 2002 and October 2003 at the Department female. Their average age was seven years (range 3½-
of Orthopaedics, Hayatabad Medical Complex, Pesha- 10 years). The left side was involved in 24 cases and
war. Patients with ligamentous instability, paralysis and the right side in six. The average time interval between
deformity resulting from firearm injuries were excluded. the fracture and the operation was 11 months (range 5-
All the children were assessed clinically and radiologi- 36 months). The average time interval between the frac-
cally and their carrying angles, range of motion (ROM) ture and the operation was 11 months (range 5-36 mon-
and the lateral condylar prominence index (LCPI) were ths). The mean pre-operative carrying angle was 25.2o
recorded. (range 18-30o). The mean desired carrying angle was
11.3o. The mean final carrying angle attained was 8.73o
Technique of operation (range 6-13o). The carrying angle differed between
All osteotomies were performed under general anaes- the normal and the injured sides by 2.6o, the difference
thesia and tourniquet control, by the Modified French being significant (Table II).
method. The humerus was approached through a small
lateral incision directly over the supracondylar ridge, The mean pre-operative range of motion was 122.6o
which was exposed susperiosteally. Pre-operatively the (range 105 to 135o). The mean post-operative range of
size of the wedge was determined from radiographs motion was 123.86o( range 90-135o). The difference
and then two cortical screws were inserted through one between the pre-operative ROM and post-operative
cortex only, above and below the proposed wedge. In ROM was 2o, the difference being non-significant. The

Table I. Bellmore Criteria for assesment of the Outcome12

Outcome ROM Carrying < LCPI Complication

Excellent Difference < 10o 5- 6o No increase None

Good Difference 10-20o 6-10o Increase <25% Minor
Poor Difference < 20o > 10o Increase >25% With residual defect
or review surgery

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 Modified French Osteotomy for Cubitus Varus deformity I. Ahmad, A. Khan, M. Idrees

mean pre-operative condylar prominence index was

175.56 (range 128-232) and the mean post-operative Grade Number %
LCPI was 156 (range 100-240), the difference between
the pre and post-operative values being significant as Excellent 25 83.3
depicted in Table II. Good 3 10.0
The operative time was 25-30 minutes with tourniquet Fair 2 6.7
control. Intra-operative blood loss ranged from 10-15
ml. No damage to nerves or blood vessels occurred dur- Table III. Overall Outcome
ing the operation. Post-operatively hand swelling occur-
red in some patients but settled on elevation of the hand and loss of range of motion, though transient ulnar
and loosening of dressing. Most of patients were satisfied nerve neuropraxia occured in three patients. This tech-
with the cosmetic outcome and none complained about nique avoids lateral scar but the disadvantages are trac-
the operative scar. We had 25 excellent, three good and tion on the ulnar nerve, requiring an anterior transposition
two poor outcomes (Table III). and a bone graft. There was no ulnar nerve neuropraxia
in our study, because the lateral closing wedge osteotomy
DISCUSSION avoids ulnar nerve damage as compared to the medial
opening wedge osteotomy.
Cubitus varus is a common complication after supra-
condylar fractures of the humerus, and there are contro- Tien et al29 reported good results of the dome corrective
versies about the timing of correction of this deformity osteotomy in respect of scar, site of osteotomy correction
and the technique of osteotomies1,2,7,8,14,17,24-26. and neurological complications as compared to the late-
ral closing wedge osteotomy. A comparative study by
The results of this study showed 25 excellent, three Kumar et al23 on dome and French osteotomy revealed
good and two poor outcomes, which are comparable no significant difference in correcting the carrying angle
with other studies. McCoy and Piggot1 performed 20 by both the techniques, though correction of the inter-
osteotomies in 1988 by a modification of French method nal rotation was significant with dome osteotomy. There
with good results in respect of physiological valgus was a higher incidence of post-operative complications
angle, range of movement and an acceptable scar. in the dome osteotomy group including infection, inade-
quate correction, nerve palsy, loss of motion and circula-
Ipplito et al27 from Rome showed in 1990 loss of correc- tory compromise, besides it is often difficult to rotate
tion (due to change in growth), ulnar nerve palsy (due in the coronal plane because of contractures of the soft
to K-wire), limitation of motion in 40% and hypertrophic tissue on the medial side, especially in the intermuscular
scar in supracondylar osteotomy. This increased rate of septum. The dome osteotomy is therefore technically
complications may be due to the difference in the cha- more difficult and has a higher complication rate.
racteristics of the patients, fixation of osteotomy by K-
wire, cubitus varus resulting from physical injury. There Karatosun et al30 from Turkey treated the cubitus varus
was no nerve palsy in our study, probably due to fixation deformity in 2000, using the Ilizarov technique of dis-
of osteotomy by screws and closing osteotomy from traction osteogenesis. They reported excellent results
the lateral side. on seven children in respect of scar, range of motion
and correction of deformity.
Walsh and Nicol28 demonstrated in 1995 that after a
medial opening wedge osteotomy and external fixation Prominence of the lateral condyle has been reported as
in 13 patients, there was no major pin tract infection a complication of supracondylar osteotomy for cubitus
Table II. Statistical Analysis of the Outcome Measures

Parameter Pre-operative Post-operative P-Value Result

mean ± SD mean ± SD

Carrying Angle 25.2o±4.7 8.7o±1.8 0.0200 Significant

o±6.9 o±7.3
Range of motion 12.6 123.8 0.4300 Non-Significant
LPCI 175.5±31.5 156±38.4 0.0049 Significant

272 Volume 23, Issue 4, 2007

 Modified French Osteotomy for Cubitus Varus deformity I. Ahmad, A. Khan, M. Idrees

varus7,24,31-33. Various authors recommend prevention Chun CH. Modified stepcut osteotomy of the hum-
of the medial displacement of the distal fragment of the erus. J Pediatr Orthop 1998; 7: 162-6.
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10. Minkowitz B, Busch MT. Supracondylar humerus
Heterotopic ossification was the major cause of limitation fractures: Current trends and controversies. Orthop
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CONCLUSION
12. Bellmore MC, Barret IR, Middleton RWP, Scongall
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gives excellent results in children. There was no neuro- Joint Surg Br 1984; 66: 566-72.
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time period. A comparative study. J Trauma 2000; 49: 717-21.

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