The Journal of Bone and Joint Surgery (American) 83:1358-1369 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.
Tardy Posterolateral Rotatory Instability of the Elbow due to Cubitus Varus
Shawn W. O'Driscoll, PhD, MD,
Robert J. Spinner, MD,
Michael D. McKee, MD,
W. Ben Kibler, MD,
Hill Hastings, II, MD,
Bernard F. Morrey, MD,
Hiroyuki Kato, MD,
Shinichiro Takayama, MD,
Junya Imatani, MD,
Satoshi Toh, MD and
H. Kerr Graham, MD
Shawn W. O’Driscoll, PhD, MD
Robert J. Spinner, MD
Bernard F. Morrey, MD
Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail
address for S.W. O’Driscoll: odriscoll.shawn{at}mayo.edu
Michael D. McKee, MD
St. Michael’s Hospital, University of Toronto, Toronto,
ON M5C 1R6, Canada
W. Ben Kibler, MD
Lexington Clinical Sports Medicine Center, 1221 South Broadway,
Lexington, KY 40504
Hill Hastings II, MD
The Indiana Hand Center, 8501 Harcourt Road, Indianapolis,
IN 46280
Hiroyuki Kato, MD
Hokkaido University School of Medicine, Kita-15, Nishi-7, Kita-ku,
Sapporo 060, Japan
Shinichiro Takayama, MD
Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku,
Tokyo 160, Japan
Junya Imatani, MD
Okayama Saiseikai General Hospital, 1-17-18 Ifukucho, Okayama
700, Japan
Satoshi Toh, MD
Hirosaki University School of Medicine, 5 Zaifucho, Hirosaki,
Aomori 036-8562, Japan
H. Kerr Graham, MD
Royal Children’s Hospital, Flemington Road, Parkville
Victoria 3052, Australia
This paper was read in part at the Closed Meeting of the American
Shoulder and Elbow Surgeons, Amelia Island, Florida, Oct 17-20,
1996, and at the Annual Meeting of the American Academy of Orthopaedic
Surgeons, Orlando, Florida, March 15-19, 2000.
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.
Background: Cubitus varus has long been considered
merely a cosmetic deformity. The purpose of this paper is to demonstrate
a causal relationship between cubitus varus and instability of the
elbow.
Methods: In twenty-four patients (twenty-five
limbs) with a cubitus varus deformity following a pediatric distal
humeral fracture or resulting from a congenital anomaly (three limbs
of two patients), tardy posterolateral rotatory instability of the
elbow developed approximately two to three decades after the deformity
occurred. All patients presented with lateral elbow pain and recurrent
instability. The average varus deformity was 15° (range, 0° to 35°).
Surgery was performed in twenty-one patients (twenty-two
limbs). Treatment consisted of reconstruction of the lateral collateral
ligament and osteotomy in seven limbs, ligament reconstruction alone
in ten, osteotomy alone in four, and total elbow arthroplasty in
one.
Results: In three patients, the triceps muscle was
dynamically stimulated intraoperatively to contract while resisting
extension of the elbow. This produced posterolateral rotatory subluxation of
the elbow, which was reversed by corrective osteotomy and lateral
transposition of a portion of the medial head of the triceps that
originally had been attached to the elongated, deformed medial aspect
of the olecranon. At an average of three years (minimum, one year)
after the operation, the result was good or excellent for nineteen
of the twenty-two limbs that had undergone an operation;
three limbs had persistent instability.
Conclusions: With cubitus varus, the mechanical
axis, the olecranon, and the triceps line of pull are all displaced
medially. The repetitive external rotation torque on the ulna permitted
by these deformities can stretch the lateral collateral ligament
complex and lead to posterolateral rotatory instability. Thus, cubitus varus
deformity secondary to supracondylar malunion or congenital deformity
of the distal part of the humerus may not always be a benign condition
and may have important long-term clinical implications.
Operative correction can relieve symptoms of instability. The indications
for preventive corrective osteotomy remain to be determined.
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