SURGICAL TECHNIQUE

Surgical Correction of Cubitus Varus

Andrea S. Bauer, MD,* Brian Pham, BS,† Lisa L. Lattanza, MD‡

Cubitus varus can arise from distal humerus fractures in childhood as a result of malunion,
nonunion, or overgrowth. Several types of distal humerus osteotomies have been described to
treat this deformity, each with its own benefits, drawbacks, and complications. This article
details the surgical technique and expected outcomes for 4 of the most commonly used types of
distal humerus osteotomies in the treatment of cubitus varus. Specifically, we will describe the
techniques for the lateral closing-wedge osteotomy, the step-cut osteotomy and its variations, the
dome osteotomy and its variations, and the multiplanar osteotomy. (J Hand Surg Am. 2016;-
(-):-e-. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights
reserved.)
Key words Cubitus varus, elbow, osteotomy, dome, step-cut.

SURGICAL TECHNIQUES

C
UBITUS VARUS IS A COMMON complication of pe-
diatric supracondylar and lateral condyle frac-
tures.1 This elbow deformity is characterized
by internal rotation, extension, and varus angulation.2
Indications for surgery are controversial. Some sur-
geons contend that this deformity is solely a cosmetic
problem, but long-term sequelae have been described,
including posterolateral rotatory instability, tardy ulnar
nerve palsy, and internal rotational malalignment.3
Timing of deformity correction is also controversial,
as these fractures generally occur well before skeletal
maturity. Currently, there is no surgical gold standard
for the correction of cubitus varus. Regardless of
technique, complications are not uncommon in the
treatment of cubitus varus.3 This review will describe
the 4 most common types of surgical osteotomies to
understand the indications, advantages, and compli-
cations of each method.
From the *Department of Orthopaedic Surgery, Shriners Hospitals for ChildreneNorthern
California; the †University of California Davis School of Medicine, Sacramento; and
the ‡Department of Orthopaedic Surgery, University of California San Francisco, San
Francisco, CA.
Received for publication February 3, 2015; accepted in revised form December 13, 2015.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Andrea S. Bauer, MD, Shriners Hospitals for ChildreneNorthern
California, 2425 Stockton Blvd., Sacramento, CA 95817; e-mail: anbauer@shrinenet.org.
0363-5023/16/---0001$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2015.12.019
Lateral wedge osteotomy
The lateral closing-wedge osteotomy is most comm-
only used for cubitus varus because of its ease and
simplicity.4 The main drawback of this approach is that
the prominence of the lateral condyle is not addressed
with this method. It has been suggested, however, that
performing this operation before age 11 will help to
reduce the lateral condylar prominence.5
The patient is positioned with the affected arm on an
arm board and a sterile tourniquet is used. A standard
lateral approach is performed, distally utilizing the in-
terval between the anconeus and extensor carpi ulnaris
muscles. Some surgeons advocate finding the radial
nerve between the brachialis and brachioradialis mus-
cles at this point to ensure that it stays protected
throughout the surgery. We have found this helpful in
older children and teenagers in whom a longer lateral
plate is required for fixation, which is more likely to
endanger the radial nerve, but it is not necessary when
pin fixation is planned in the skeletally immature pa-
tient. The principle behind this closing-wedge osteot-
omy is to plan a distal cut parallel to the (altered) joint
line and a proximal cut perpendicular to the long axis
of the humerus. The removal of the wedge then places
the joint line in proper alignment with the humeral axis.
However, this technique is criticized for causing sig-
nificant lateral prominence. To minimize the lateral
prominence, both cuts can be made obliquely to re-
create the same wedge angle without having the distal

Ó 2016 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 CUBITUS VARUS
FIGURE 1: The lateral closing-wedge osteotomy. The dotted lines
mark the planned osteotomy sites. Although the planned cuts are
oblique to the joint line, they recreate the same angle that would be
made by placing one wire perpendicular to the humeral axis and
another wire parallel to the joint line. Note that 2 Kirschner wires
have already been placed in the lateral condyle to be driven across
the osteotomy immediately after completion.
cut completely parallel to the joint line. When pin fix-
ation is planned, it is helpful to first place 2 Kirschner
wires in the lateral condyle distally, so that when the
wedge is removed, the pins can be driven across the
osteotomy site into the medial cortex (Fig. 1).
Some surgeons prefer to completely cut the medial
cortex of the humerus, whereas others have recom-
mended leaving a medial cortical hinge.6 Leaving an
intact medial cortex allows for lesser fixation methods,
such as pins, because the osteotomy is inherently more
stable. However, this technique then does not allow for
correction in the rotational or sagittal planes. After the
removal of the wedge, a standard supracondylar frac-
ture reduction maneuver of valgus, hyperflexion, and
pronation is performed and the preplanned Kirschner
wires are driven across the osteotomy. If additional
fixation is required, a third wire or a lateral plate can
be used. Plate fixation may have an advantage over
pin fixation in allowing earlier mobilization, but it re-
quires a more extensive dissection, is more technically
demanding, and may require future hardware removal.
J Hand Surg Am.
After closure, the patient is placed in a long-arm bi-
valved cast with a plan for approximately 6 weeks of
immobilization.4
Complications from lateral wedge osteotomies are
reported between 14% and 53%.1 The most common
complication is prominence of the lateral condyle. This
has been reported to occur in up to 60% of cases and
arises more commonly when the medial cortex is pre-
served for hinge stability. Another complication is the
loss of correction when Kirschner wires alone are used
for fixation.7 Oppenheim et al6 described other com-
plications such as unacceptable scarring, neuropraxia,
and sepsis in 24% of cases.
From a cosmetic standpoint, a lateral approach may
cause unsatisfactory scarring. Hui et al8 described a
medial approach to minimize both the lateral scar and
the lateral condylar prominence. In this approach, a
medial incision is made and lateral-based closing-wedge
osteotomy is performed through the medial incision.
Two Kirschner wires and an image intensifier are used to
determine the placement of the wedge. Kirschner wires
are used as guides for the osteotomy and the distal
fragment is translated medially, thus reducing the lateral
prominence.8
Step-cut osteotomy
The concept of a step-cut osteotomy arose to combat
the lateral condylar prominence and other complica-
tions of the lateral wedge osteotomy. The traditional
step-cut osteotomy first described by De Roza and
Graziano is a closing-type technique. The distal frag-
ments have a lateral spike that is fixed to the proximal
segments. Instead of the traditional step-cut osteotomy,
the translational step-cut and spike translational modi-
fied step-cut osteotomies are described here.1,9,10
Davids et al1 provides an excellent description of
the translational step-cut osteotomy. The patient is
positioned in either a prone or lateral position, with
the humerus supported on a padded post. A standard
posterior approach to the elbow is used. The triceps-
splitting approach offers the best visualization of the
entire posterior aspect of the distal humerus, which is
required for this approach. The triceps muscle is split
longitudinally after identification of its medial and
lateral margins. After identification of the distal hu-
merus and superior margin of the olecranon fossa, the
first cut is a proximal transverse cut perpendicular to
the axis of the humerus. The amount of correction
needed is calculated as an angle, and a distal cut angled
posterior-medially to distal-laterally is made at this
angle to the proximal transverse cut. This creates a
lateral triangular wedge that is removed for the corre-
ction of the deformity. A rectangular wedge according
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 CUBITUS VARUS
FIGURE 2: The step-cut osteotomy. The dotted lines mark the
planned osteotomies. Again Kirschner wires can be preplaced in
the distal fragment to allow for immediate fixation after completion
of the osteotomies.
to the size of the step cut is then made proximal and
lateral to the transverse cut. This rectangular segment is
then removed to allow for translation and medializa-
tion of the distal segment, which eliminates the lateral
condylar prominence (Fig. 2). Davids used lateral and
medial Kirschner wires for fixation; others have
described the use of distal humeral plates.1,11
The spike translation step-cut osteotomy is some-
what more complex requiring preoperative calculation
of not only the varus correction but also the necessary
horizontal translation to correct the lateral prominence.
A paratricipital or olecranon osteotomy approach is
used. A closing-wedge osteotomy is performed corre-
sponding to the amount of correction by comparing the
carrying angle of both upper extremities. The inferior
margin of the triangle is made parallel to the joint line
0.5 cm above the olecranon fossa. The second line is
drawn from medial distal to proximal lateral to make the
desired angle of correction. Next, from the lateral end of
the second line a third perpendicular line is drawn
distally meeting the first line. This outlined triangle is
now removed. The precalculated horizontal correction
of the distal fragment is completed by translating the
distal fragment the appropriate distance on the proximal
J Hand Surg Am.
3
fragment. A corresponding triangular notch of bone is
resected then from the proximal fragment to match the
distal fragment and the 2 are interdigitated. If planned
preoperatively, internal rotational deformity is cor-
rected through rotation of the distal fragment. Plates and
screws are used for fixation.10
Both the translational and spike-modified step-cut
osteotomies have complications to consider.1,10,11 For
the translational step-cut osteotomy, Davids et al1
reported a complication rate of 19%, consisting of tran-
sient nerve palsy and loss of fixation. These complica-
tions did not occur in the series of cases by Moradi et al. It
is more difficult to perform spike osteotomies on smaller
and younger pediatric patients. Also, spike osteotomies
require a larger bone resection compared with transla-
tional step-cut osteotomies and lateral closing-wedge
osteotomies.10
Dome osteotomy
The dome osteotomy is more technically demanding
than either the lateral wedge or the step-cut osteot-
omy.12 The dome osteotomy avoids the lateral promi-
nence produced by the lateral closing-wedge osteotomy
while providing a large surface area for fixation and
healing, and the ability to “dial in” the desired amount
of correction. The lateral condylar prominence is
decreased because the axis of rotation for the dome
osteotomy is at the center of the distal humerus, obvi-
ating the need for the lateral translation inherent in the
wedge osteotomy.13 In addition, rotational deformity
can be corrected.
The patient is positioned in either a lateral or prone
position, with the humerus supported on a padded post.
Either a triceps-splitting or para-tricipital approach can
be used. After the exposure of the distal humerus, the
olecranon fossa is identified. The center of the dome
osteotomy (point A) is the point at which the midline
axis of the humerus intersects with the upper margin of
the olecranon fossa. From point A, the base segment
line AB is marked perpendicular to the midline axis of
the humerus. Line AB0 is then drawn parallel to the
distal humeral articular surface. The length of AB0
determines the radius of the dome osteotomy. The arc
of the dome osteotomy is marked with Kirschner wires
and then drilled with a 3-0 cannulated drill bit. A
quarter inch osteotome is used to finish the dome
osteotomy. Alternatively, a dome-shaped oscillating
saw can be used (TPLO saw, Whittemore Enterprises,
Rancho Cucamonga, CA). Point B0 on the distal frag-
ment is then rotated to point B on the proximal frag-
ment and provisionally fixed with Kirschner wires.14 It
is helpful to place those wires in the distal fragment
before performing the osteotomy to aide in reduction
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4 CUBITUS VARUS
FIGURE 3: The dome osteotomy. Point A marks the intersection of
the midline axis of the humerus with the olecranon fossa. AB is
drawn perpendicular to the midline axis of the humerus. AB0 is
drawn parallel to the (altered) distal humeral joint line, so that the
angle BAB0 marks the angle needed for correction. The dome is
then drawn with line AB0 as its radius. After the dome osteotomy is
completed, the distal humerus is rotated so that B and B0 are the
same point.
and fixation. In young children, Kirschner wires alone
are sufficient for fixation (Fig. 3). In older children and
teenagers, however, standard distal humerus plates are
used. Postoperative immobilization is used from 2 to 6
weeks depending on the type of fixation.
Eamsobhana and Kaewpornsawan performed a
double dome osteotomy to more fully address both the
coronal and sagittal plane deformities in cubitus varus.
They used a lateral approach. The first dome osteotomy
was at the apex of the olecranon fossa, with the center
of the dome aligned with the humeral midline axis.
The second dome osteotomy was also at the apex of
the olecranon fossa, but with the center of the dome
aligned with the midline axis of the ulna. The 2 domes
overlap, creating 2 semicircular wedges for removal.
After bone removal, the osteotomies are translated so
that the humeral axis is aligned with the ulnar axis, thus
correcting the varus and extension deformity. Cross-
pin fixation is used for this double dome osteotomy.
In their series of 18 patients followed for an average of
J Hand Surg Am.
FIGURE 4: A computer-generated model of the affected arm (in
white) is superimposed on a mirror image of the unaffected arm
(in blue) to demonstrate the amount of correction needed to
normalize the deformity.
4 years, the only reported complications were 1 su-
perficial infection and 1 transient radial nerve palsy.2
With both the single and double dome osteotomies,
lateral condylar prominence is less likely, and high pa-
tient satisfaction with appearance has been reported.2
However, other complications included transient radial
nerve palsy, superficial infection, and excessive der-
otation.12 One series found a higher rate of radial nerve
palsy using the posterior triceps-sparing approach.3
Similarly, Raney et al15 noted similar overall rates of
complications with both lateral and posterior ap-
proaches but associated a higher rate of nerve palsies
with the posterior approach.
Multiplanar osteotomy
The previous osteotomies do not always address the
rotational deformity associated with cubitus varus that
may also contribute to tardy ulnar nerve palsy and altered
mechanics at the elbow joint.16 Multiplanar osteotomies
can more accurately correct internal rotation than uni-
planar osteotomies, thus, allowing for anatomical posi-
tioning of the distal humerus. Rotational deformity is
difficult to understand through conventional radiographs,
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 CUBITUS VARUS
FIGURE 5: A computer-generated model of the planned osteot-
omy and resulting correction.
and so accurate planning of multiplanar osteotomies re-
quires a preoperative computed tomography scan.16,17
This technique begins with a spiral computed tomo-
graphy scan of both arms. The surgeon can then work
with either a company, such as Materialise (Leuven,
Belgium), or commercially available software, such as
Bone Viewer and Bone Simulator, to generate a surface
3-dimensional model for the radius, ulna, and humerus.
Within the software, the entire affected arm and the
healthy humerus are superimposed to determine the
correction of the deformity (Fig. 4). The greater tuber-
osity, humeral head, and shaft are used as proximal
reference points, and if possible the lateral and medial
epicondyles are used as distal reference points. The distal
osteotomy plane is placed proximal to the olecranon
fossa and parallel to the distal surface of the humerus.
Then, the proximal osteotomy plane is determined by
the correction for the deformity in relation to the distal
osteotomy plane (Fig. 5).16 On the basis of this model, the
surgeon can then create patient-specific cutting guides
as well as custom surgical fixation devices if needed.
Depending on the planned osteotomies, either a
lateral or posterior approach can be used. The surgical
guide is generally placed onto the posterolateral surface
of the distal humerus. The surgical template must make
complete contact at the exact location for accuracy and
J Hand Surg Am.
5
FIGURE 6: The 3-dimensional osteotomy. Dotted lines represent
the planned osteotomies, which are made using preformed
patient-specific cutting guides.
correctness. Kirschner wires are inserted into the bone to
hold the guide in place. An oscillating saw is used to
perform the planned osteotomies through slits in the
guide. The guide is then removed, leaving the wires in
place. After the guide removal, the wedge(s) is removed.
The Kirschner wires on the proximal fragment act as
guides for the rotation and translation of the distal
fragment. The wires on the distal fragment are posi-
tioned until it aligns with the proximal wires for com-
plete correction. Different types of fixation can be used,
such as Kirschner wires, tension band wiring, standard
plates and screws, or custom devices (Fig. 6).16
This technique can accurately correct not only varus
but also the extension and internal rotation that are part
of the cubitus varus deformity, improving both appear-
ance and function. However, this technique does have
some drawbacks. The first issue is access and cost
effectiveness. A bilateral computed tomography scan is
required, which may not be readily available to all pa-
tients. Another consideration is whether the correction of
the internal rotation deformity is even necessary. Takagi
et al18 have suggested that internal rotation correction
does not affect the outcome of cubitus varus correc-
tions.18 However, others have suggested that excessive
internal rotation may be related to the development of
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6 CUBITUS VARUS
tardy ulnar nerve palsy.19 It is possible that patients could
maintain their daily life activities without difficulties
despite the loss of internal rotation, as long as ulnar ne-
rve function remains intact. If this is the case, the benefits
of 3-dimensional osteotomies may not outweigh the
additional risks and cost.
In summary, there is no gold standard surgical cor-
rection for cubitus varus and multiple types of osteoto-
mies exist to correct these deformities in children. Lateral
wedge osteotomies are performed most commonly, and
the technique is simple, effective, and reproducible. Yet,
multiple complications, most notably the lateral condylar
prominence, have been documented and have led many
surgeons to consider alternate approaches. The step-
cut and dome osteotomies attempt to correct cubitus
varus without causing the lateral prominence. However,
these techniques have potentially higher complication
rates and are more technically demanding. Although
multiplanar osteotomies have the potential to correct
cubitus varus with fewer complications, the difficulty of
obtaining custom surgical guide templates for each pa-
tient prevents this from currently becoming the gold
standard. Further research requires consideration for a
simple and effective surgical technique with minimal
complication and maximum patient satisfaction.
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