Three-Dimensional Correction of Cubitus Varus Deformity Using Patient-Specific 3D-Printed Osteotomy Guides

Three-Dimensional Correction of Cubitus Varus Deformity Using Patient-Specific 3D-Printed Osteotomy Guides | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Three-Dimensional Correction of Cubitus Varus Deformity Using Patient-Specific 3D-Printed Osteotomy Guides Mei-Ren Zhang, Jian-Hao Guan, Hai-Yun Chen, Kui Zhao, Jian-Hui Hu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6595195/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background : Various three-dimensional (3D) corrective osteotomy techniques have been reported for the treatment of cubitus varus deformity. However, achieving accurate correction through a minimally invasive incision remains technically challenging. This study introduces a method for accurate 3D osteotomy of cubitus varus deformity using a minimally invasive lateral incision. Methods : Five patients (2 males and 3 females) with cubitus varus deformity following supracondylar fracture underwent 3D corrective osteotomy using 3D-printed, patient-specific osteotomy templates, along with custom location and reduction guides, between August 2022 and January 2025. These cases were evaluated retrospectively. Clinical outcomes assessed included pre- and postoperative carrying angles, operative time, elbow joint function, intraoperative blood loss, degree of osteotomy, time to bone union, and postoperative complications. Results : The mean carrying angle on the affected side improved significantly from − 15.74° ± 6.58° (varus) preoperatively to 7.77° ± 3.94° (valgus) postoperatively. The mean tilting angle improved from 54.8° ± 7.40° to 51.4° ± 2.33°. Elbow range of motion normalized in all patients, with a mean increase in flexion angle of 24° ± 8° (range: 15°–35°). Hyperextension of the elbow and internal rotation of the shoulder were also corrected. Bone union was achieved at a mean of 2.6 ± 0.49 months (range: 2–3 months). The average operative time was 139.6 ± 22.26 minutes (range: 116–175 minutes), and mean intraoperative blood loss was 42 ± 31.87 mL (range: 10–100 mL). The mean correction angle achieved through osteotomy was 23.51° ± 8.79° (range: 12.43°–33.43°). According to the Mayo Elbow Performance Index (MEPI), all five patients achieved excellent outcomes at the final follow-up (mean: 21.6 ± 4.8 months), with no reports of poor results, recurrence of varus deformity, or wound-related complications. One patient exhibited transient ulnar nerve symptoms postoperatively. No patients reported prominence of the lateral humerus. Conclusion : The use of a 3D-printed, patient-specific osteotomy guide combined with custom location and reduction templates enables safe, accurate, and reproducible 3D correction of cubitus varus deformity through a minimally invasive lateral incision. This surgical technique, grounded in 3D computer simulation, reduces variability between surgeons and may represent a viable therapeutic option for the correction of cubitus varus deformity. Cubitus varus deformity three-dimensional printing custom-matched surgical osteotomy template reduction templates accurate osteotomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction Cubitus varus deformity is a common complication following a supracondylar fracture of the humerus ( 1 – 4 ). Accurate correction of all three deformity components is essential to prevent long-term sequelae, including limited elbow flexion, joint instability, tardy ulnar nerve palsy, and to achieve satisfactory cosmetic results ( 5 – 12 ). Although various surgical methods have been proposed to correct cubitus varus deformity ( 13 – 16 ), achieving accurate correction of this complex, three-dimensional (3D) deformity remains technically challenging. The condition involves deformity in all three planes: varus angulation in the coronal plane, hyperextension in the sagittal plane, and internal rotation in the horizontal plane. As such, triplanar osteotomy techniques have been recommended to achieve comprehensive 3D correction ( 14 , 17 ), despite their associated technical demands and surgical risks ( 18 – 23 ). Recent advances in computer simulation and the development of custom-matched surgical guides and implants using 3D printing have addressed many of these challenges, enabling more accurate, straightforward, and safer 3D corrections ( 22 – 26 ). However, differences in surgical incisions and fixation methods remain across techniques. In this study, we introduce a minimally invasive, laterally approached 3D corrective osteotomy for cubitus varus deformity, utilizing preoperative computer simulation and custom 3D-printed surgical templates. We also present clinical and radiographic outcomes of this approach. Materials and methods Subjects Between August 2022 and June 2025, five consecutive patients with cubitus varus deformity (Table 1)—resulting from malunion of a distal humerus supracondylar fracture—underwent 3D corrective osteotomy using 3D-printed, patient-matched surgical osteotomy guides, along with custom location and reduction templates. The procedure was performed through a minimally invasive lateral incision and was based on preoperative computer simulation using 3D CT models. Table 1: Details of Patients for 3D corrective osteotomy for cubitus varus deformity Patient No./ Sex/Age, y age at initial injury，year Elbow Mechanism of Injury Time From Injury to Surgery, mo Follow-up, mo MEPI Score operation time,min intraoperative blood loss,ml increased flexion angle osteotomy degrees Osteotomy end union time,mo postoperative complications 1/Fe/11 2/M/37 3/Fe/7 4/Fe/11 5/Fe/44 11 9 3 5 9 L L R R L Fall Fall Fall Fall Fall 8 336 48 72 420 35 29 24 12 6 100 100 100 100 100 116 175 152 117 138 20 100 10 30 50 30 35 15 15 25 34.33 33.40 12.42 17.69 19.71 3 2 2 3 3 No No No Ulnar nerves injury No Mean 7.4 176.8±167.7 21.6±4.8 139.6±22.26 42±31.87 24°±8 ° 23.51°±8.79° 2.6±0.49 Details of Patients for 3D corrective osteotomy for cubitus varus deformity The mean age at the time of initial injury was 7.4 ± 2.94 years (range: 3–11 years). All five patients (3 males and 2 females) underwent postoperative X-ray examination and were evaluated retrospectively, with a mean follow-up period of 21.1 ± 10.7 months (range: 6–35 months). The mean age at the time of corrective osteotomy was 22.2 ± 15.2 years (range: 7–44 years), and the mean duration from injury to surgery was 177 months (range: 8–420 months). Four of the five patients had been treated with cast immobilization for the initial fracture, while one had undergone open reduction and internal fixation with Kirschner wires. All patients presented with unilateral elbow deformity and reported dissatisfaction with the cosmetic appearance of the affected limb. In addition to aesthetic concerns, three patients (Cases 1, 2, and 5) experienced restricted elbow flexion exceeding 20° compared with the unaffected side. No patient reported hyperextension of the elbow. Image Acquisition and Preoperative Simulation Step 1: 3D Evaluation of Cubitus Varus Deformity Computerized Tomography (CT) data of both humeri were obtained, and corresponding 3D bone models were created. Scanning was performed with the forearms in maximum supination using a low-radiation dose protocol on a CT scanner (General Electric LightSpeed-640, GE, Milwaukee, WI) with a slice thickness of 0.5 mm. Three-dimensional surface models of both humeri were generated from the imaging data, and the deformity was evaluated by comparing the affected humerus with the mirrored image of the contralateral, normal side using 3D modeling software (Magics RP; Materialise, Leuven, Belgium) (Fig. 1 A– 1 B).The proximal part of the affected humerus was superimposed onto the mirrored image of the corresponding area on the normal side (proximal registration) (Fig. 1 C). The same process was applied to the distal humerus (distal registration). The software calculated the 3D magnitude of deformity automatically by analyzing the transformation data required to align both the proximal and distal segments. Step 2: Planning the 3D Corrective Osteotomy A simulated 3D corrective osteotomy was performed based on the deformity analysis. Two osteotomy planes were created using the software: the proximal osteotomy plane (POP) and the distal osteotomy plane (DOP). The POP was defined by positioning a virtual plane perpendicular to the humeral axis, approximately 0–1 cm proximal to the olecranon fossa on the mirrored image of the normal side. This plane was saved as the POP (Fig. 2 A).To define the DOP, the distal part of the affected humerus was aligned with the mirrored distal humerus of the normal side, and the DOP was positioned accordingly (Fig. 2 B). The wedge-shaped segment between the POP and DOP was digitally removed using the software's edit function (Fig. 2 C– 2 D). To complete the correction simulation, the distal segment of the affected humerus was repositioned to meet the proximal segment (Fig. 2 E), and the final alignment was visually verified to confirm the restored anatomy (Fig. 2 F). Step 3: Design of Patient-Specific Surgical Templates 1) Design of the Custom-Made Surgical Reduction Template The wedge-shaped segment between the distal and proximal osteotomy planes (DOP and POP) was removed from the affected humerus. The simulation of 3D correction was completed by repositioning the distal humerus segment to align with the proximal segment. A custom reduction template was designed to fit the posterolateral surface of the corrected distal humerus. Four guide pins were positioned parallel to each other along the midline of the lateral distal humerus, perpendicular to the humeral axis, with 8 mm spacing and a diameter of 2.0 or 2.5 mm (Fig. 3 A). The midpoint between the second and third guide pins was placed on the osteotomy surface (Fig. 3 B). Pin spacing and diameter could be adjusted based on the patient’s bone size. The surgical reduction template was then designed using SolidWorks software based on the placement and orientation of the four guide pins (Fig. 3 C– 3 D). This template was used to assist with reduction and temporary fixation during surgery. 2) Design of the Custom-Made Surgical Osteotomy Template The surgical reduction template was divided into upper and lower components along the proximal osteotomy plane (POP) using the software. The distal humerus of the affected side was then returned to its original uncorrected position (Fig. 4 A– 4 B). Two osteotomy slits were designed through the POP and DOP, each connected to the corresponding section of the reduction guide by a connecting rod to enhance template stability (Fig. 4 C– 4 D). The final osteotomy guide plate was generated after fitting it to the lateral surface of the distal humerus using SolidWorks software (Fig. 4 E– 4 F). 3) Design of the Custom-Made Location Template Two guide pins were placed proximal to the POP on the affected humerus and designated as positioning guide pins. A corresponding positioning guide plate was designed using 3D modeling software (SolidWorks) to match the lateral surface of the distal humerus (Fig. 4 G– 4 H). Step 4: Preoperative Simulation Preoperative simulation the 3D corrective osteotomy was conducted using computer software, incorporating the custom-made osteotomy, location, and reduction templates (Fig. 5 A- 5 E). A corresponding 3D-printed model was also created to replicate the planned procedure (Fig. 6 A- 6 H). Step 5: Surgical Technique Case Presentation A 44-year-old female sustained a supracondylar fracture of the left humerus at the age of nine. She was treated with immobilization using a cast; however, the cubitus varus deformity persisted for 35 years after the injury (Fig. 7 A). A 3D evaluation of the deformity, based on comparison with the mirrored image of the normal contralateral side, revealed the following: 27° of varus, 0° of extension, and 10° of internal rotation deformity (Fig. 7 B– 7 C). The preoperative carrying angles (CA) of the normal and affected sides were 13.8° and − 13.4°, respectively. The preoperative tilting angles (TA) were 52° and 39°, respectively. The distal part of the humerus was exposed through a lateral approach (8cm incision) with the patient in the supine position. Two 2.5 mm Kirschner wires were inserted through the location guide once the guide edges were in full contact with the lateral humeral surface (Fig. 8 A). The location guide was then replaced with a custom-made surgical osteotomy template secured by the same wires. Two additional 2.5 mm Kirschner wires were inserted through the remaining guide channels to ensure firm contact with the bone surface (Fig. 8 B). Osteotomy was performed using a saw through the slits in the guide (Fig. 8 C), followed by removal of the wedge-shaped bone segment. The correction was achieved by aligning the four Kirschner wires in parallel and securing them temporarily using the reduction template, which fit snugly against the bone surface (Fig. 8 D). Another Kirschner wire was inserted through the reduction guide to stabilize the reduction (Fig. 8 E). For patients with closed physes, internal fixation was performed using a lateral locking compression plate (LCP), as planned preoperatively (Fig. 8 F). The lateral Kirschner wire was removed while the medial one was retained. Alignment was confirmed intraoperatively with C-arm fluoroscopy (Fig. 8 G– 8 H). Immediately after surgery, the passive range of motion was normal, and the deformity was successfully corrected through the 8 cm lateral incision (Fig. 8 I– 8 K). Both active and passive range-of-motion exercises were started the day after surgery without the use of a splint. Two weeks postoperatively, elbow flexion improved from 120° to 145° and extension from 10° to 0°. Pronation and supination of the forearm also returned to normal (Fig. 9 A– 9 D). The carrying and tilting angles were corrected to 6.3° and 48°, respectively. Photographs and anteroposterior/lateral radiographs confirmed accurate correction of the deformity in the left elbow (Fig. 9 G– 9 I). Results The mean carrying angle and tilting angle on the affected side improved significantly from − 15.74° ± 6.58° (varus) and 54.8° ± 7.40°, respectively, before surgery, to 7.77° ± 3.94° (valgus) and to 51.4° ± 2.33°, respectively, after surgery(Table 2 ). The elbow range of motion returned to normal, with an increase in flexion angle of 24° ± 8° (range: 15°–35°). Hyperextension of the elbow and internal rotation of the shoulder were normalized in all patients. Bone union was achieved at a mean of 2.6 ± 0.49 months (range: 2–3 months) after surgery. Operation time averaged 139.6 ± 22.26 minutes (range: 116–175 minutes), and mean intraoperative blood loss was 42 ± 31.87 mL (range: 10–100 mL). The mean osteotomy correction achieved was 23.51° ± 8.79° (range: 12.43°–33.43°).According to the MEPI (Mayo Elbow Performance Index) assessment, all five patients had excellent outcomes at the final follow-up (mean: 21.6 ± 4.8 months), and none had poor results. No patient experienced a recurrence of the varus deformity. No wound-related complications occurred, although one patient showed evidence of neurovascular injury involving the ulnar nerve. No patients reported prominence of the lateral humerus. Table 2 pre- and postoperative carrying angles and Tiling Angle Radiographic Parameters Radiographic Parameters Clinical Parameters Carrying Angle (deg) Tiling Angle (deg) case Preop. Postop. Normal Side Preop. Postop. Normal Side 1 -22.13 12.2 15.29 36 52 52 2 -22.18 11.22 8.43 49 52 52 3 -4.41 8.02 10.21 40 55 53 4 -16.54 1.15 3.07 56 50 50 5 -13.43 6.28 19.71 39 48 53 Mean -15.74 ± 6.58 7.77 ± 3.94 10.17 ± 5.72 54.8 ± 7.4 51.4 ± 2.3 52 ± 1.1 Discussion In adolescents, Cubitus varus deformity is the most common complication following distal humeral fractures ( 22 ). Recent studies have demonstrated that cubitus varus is a 3D deformity involving not only varus angulation but also extension and internal rotation of the distal humeral segment ( 18 , 27 , 28 ). As a result, corrective approaches have increasingly focused on 3D techniques to achieve comprehensive improvements in function and appearance ( 26 , 29 – 32 ). However, accurately correcting angular deformities in all three planes remains technically challenging for surgeons. It often requires repeated intraoperative adjustments or visual estimation, which may lead to substantial deviations from the desired alignment and suboptimal outcomes ( 22 ). Recent advances in computer simulation technology, along with the use of patient-specific surgical guides and implants created through 3D printing, have addressed many of the challenges associated with correcting cubitus varus deformity. These technologies have enabled accurate, simple, and safe 3D osteotomy procedures ( 22 – 26 ). Several studies have reported excellent outcomes and improved osteotomy accuracy, leading many authors to recommend this technique as an ideal treatment approach for cubitus varus deformity ( 22 , 26 , 29 , 33 – 34 ). For example, Jiang et al. ( 23 ) reported that the combined rate of excellent and good outcomes was 92.3%. Takeyasu et al. ( 26 ) described the use of custom-made osteotomy templates in 30 cases of cubitus varus deformity, with 90% of patients achieving excellent results and the remaining 10% achieving good results. However, compared with conventional procedures, 3D-guided osteotomy often requires a larger surgical field to accommodate the guide. Sri-Utenchai et al. ( 35 ) used a standard posterior paratricipital approach with a 20-cm posterior midline incision. Zhang et al. ( 22 ) reported the use of double incisions (medial and lateral) in their study. Omori et al. ( 29 ) used a lateral approach in 7 cases and a posterior approach in 10 cases, though incision lengths were not specified. Takeyasu et al. ( 26 ) also used a lateral approach but did not report incision length. In this study, we applied a 3D-printed, patient-specific surgical osteotomy template combined with location and reduction guides to perform accurate 3D corrective osteotomy for cubitus varus deformity through a minimal lateral incision. All patients achieved excellent outcomes, including improved cosmetic appearance, no loss of correction, and no delayed or nonunion at the osteotomy site. There are several reasons why a single, small lateral incision was sufficient to achieve accurate 3D correction in our cases. First, we used a conventional closed lateral wedge osteotomy. An 8 cm lateral incision was sufficient to allow the osteotomy template to be properly attached to the lateral surface of the distal humerus. Second, although our osteotomy template was relatively larger than those used in some previous studies ( 22 , 36 – 38 ), we designed and added a location template that was smaller than the main guide. Two location Kirschner wires were accurately inserted using this smaller guide through the 8 cm incision. Afterward, the smaller guide was replaced with the larger osteotomy template without requiring additional incision length. This method ensured a secure fit and prevented loosening or shifting of the guide during osteotomy, thereby improving surgical precision. Third, the reduction guide was specifically designed to assist with post-osteotomy alignment by temporarily holding the four Kirschner wires in a parallel position. This not only ensured an accurate reduction without extending the original incision but also significantly shortened the reduction time. Using this technique, all five patients achieved single-attempt osteotomy success. Postoperative appearance and correction angles matched the preoperative plan and bone healing was confirmed at the osteotomy site approximately three months after surgery. However, several practical considerations should be noted when applying this technique clinically. First, the cutting slits on the osteotomy template were prone to breakage due to oscillation of the bone saw during the procedure, particularly when the slit thickness was insufficient. To address this, we increased the thickness of the cutting slits to at least 3 mm and prepared two surgical guides for each case, both of which were sterilized prior to surgery. One patient developed ulnar nerve paralysis postoperatively due to the placement of the medial Kirschner wire. The nerve function fully recovered after immediate wire removal and four weeks of treatment with neurotrophic agents. Following this event, we began using a 1 cm incision over the medial epicondyle to expose the entry point for the medial Kirschner wire directly, and no further ulnar nerve injuries occurred. Several practical considerations should be noted when applying this technique clinically. First, the cutting slits on the osteotomy template were prone to breakage due to oscillation of the bone saw during the procedure, particularly when the slit thickness was insufficient. To address this issue, we increased the slit thickness to at least 3 mm and prepared two surgical guides per case, both of which were sterilized prior to surgery. One patient developed ulnar nerve paralysis postoperatively due to the placement of the medial Kirschner wire. The nerve function fully recovered after immediate wire removal and four weeks of treatment with neurotrophic agents. Following this event, we began using a 1 cm incision over the medial epicondyle to directly expose the Kirschner wire entry point, and no further ulnar nerve injuries were observed. Although previous reports have described limitations of 3D-printed guide plates, such as a risk of correction loss due to reduced bone contact area and compromised fixation stability ( 21 , 39 – 42 ), our study did not observe these issues. There were no cases of correction loss, delayed union, nonunion, or fixation failure in our study. This may be attributed to the use of lateral LCP plate fixation combined with medial pinning, which provided sufficient stability for early active functional exercise after surgery. Radiation exposure from CT imaging is another concern ( 20 , 21 , 36 ), but this can be minimized through low-dose imaging protocols and improved image-processing technologies. A commonly cited disadvantage of 3D printing is the requirement for additional equipment and software for simulation and model generation. However, our team handled all design and printing in-house, which significantly reduced both production time and cost. Previous studies have also suggested that patient-specific guides may reduce the risk of revision surgery by lowering complication rates and overall medical expenses. Finally, this was a retrospective, non-randomized study with a limited sample size and a relatively short follow-up period, which may introduce subjective bias. Conclusion 3D-printed, patient-specific surgical osteotomy guides—combined with location and reduction templates—enable simple, safe, and accurate 3D correction of cubitus varus deformity through a small lateral incision. Based on computer simulation, this surgical technique is highly reproducible and may help minimize differences in surgeon skill. It may serve as a viable therapeutic option for correcting cubitus varus deformity. Declarations Declarations Ethical Approval: This study was performed in line with the principles of the Declaration of Helsinki.The patient agreed to participate in this study. Informed consent was obtained from the patient or the patient's and legal guardian prior to the study. This study was approved by Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine Consent for publication: Written informed consent was obtained from the patients or the patient's and legal guardian for publication of this study and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials ： The data used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests ： All Authors declared no benefits in any form have been, or will be received, from any commercial party related directly, or indirectly, to this study. Funding: 2024 Science and Technology Innovation Bureau of Zhuhai city（number ZH22036201210076PWC）were received in support of this study. No benefits in any form have been, or will be received, from any commercial party related directly, or indirectly, to this study. Author contributions ： Mei-Ren Zhang designed the study and wrote the manuscript. Jian-Hao Guan, Hai-Yun Chen and Kui-Zhao,Jian-Hui Hu were involved in the treatment. Xiao Zeng performed literature review.Jiang-long Guo performed data collection and processing，All authors contributed to writing the manuscript. All authors read and approved the manuscript. Acknowledgement ： Not applicable References Devnani AS. Late presentation of supracondylar fracture of the humerus in children. Clin Orthop Relat Res. 2005 Feb;(431):36-41. doi: 10.1097/01.blo.0000152439.43810.11. Lal GM, Bhan S. Delayed open reduction for supracondylar fractures of the humerus. Int Orthop. 1991;15(3):189-91. doi: 10.1007/BF00192291. O'Hara LJ, Barlow JW, Clarke NM. Displaced supracondylar fractures of the humerus in children. Audit changes practice. 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Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device. J Bone Joint Surg Am. 2013 Nov 20;95(22):e173. doi: 10.2106/JBJS.L.01622. Ho CA. Cubitus Varus-It's More Than Just a Crooked Arm! J Pediatr Orthop. 2017 Sep;37 Suppl 2:S37-S41. doi: 10.1097/BPO.0000000000001025. Gorelick L, Robinson D, Loberant N, Rozano-Gorelick A, Yassin M, Garti A, Ram E. Assessment of the normal and pathological alignment of the elbow in children using the trochleocapitellar index. BMC Musculoskelet Disord. 2014 Feb 27;15:60. doi:10.1186/1471-2474-15-60. Omori S, Murase T, Oka K, Kawanishi Y, Oura K, Tanaka H, Yoshikawa H. Postoperative accuracy analysis of three-dimensional corrective osteotomy for cubitus varus deformity with a custom-made surgical guide based on computer simulation. J Shoulder Elbow Surg. 2015 Feb;24(2):242-9. doi: 10.1016/j.jse.2014.08.020. Epub 2014 Oct 25. North D, Held M, Dix-Peek S, Hoffman EB. French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years. J Pediatr Orthop. 2016 Jan;36(1):19-24. doi: 10.1097/BPO.0000000000000405. Tanwar YS, Habib M, Jaiswal A, Singh S, Arya RK, Sinha S. Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note. J Shoulder Elbow Surg. 2014 Nov;23(11):1612-7. doi: 10.1016/j.jse.2014.06.030. Epub 2014 Sep 17. Takeyasu Y, Murase T, Miyake J, Oka K, Arimitsu S, Moritomo H, et al. Three-dimensional analysis of cubitus varus deformity after supracondylar fractures of the humerus. J Shoulder Elbow Surg. 2011;20:440–8. https://doi.org/10.1016/j.jse.2010.11.020 Bovid KM, Kohler EJ, Habeck JM, Gustafson PA. Utilization of a 3D-printed model for preoperative planning and operative osteotomy of a pediatric cubitus varus deformity. JSES Open Access. 2019 Aug 9;3(3):219-224. doi: 10.1016/j.jses.2019.05.003. Oka K, Murase T, Okada K, Tanaka H, Yoshikawa H. Single-plane rotational osteotomy for cubitus varus deformity based on preoperative computer simulation. J Orthop Sci. 2019 Sep;24(5):945-951. doi: 10.1016/j.jos.2017.04.012. Epub 2017 May 21. Sri-Utenchai N, Pengrung N, Srikong K, Puncreobutr C, Lohwongwatana B, Sa-Ngasoongsong P. Three-dimensional printing technology for patient-matched instrument in treatment of cubitus varus deformity: A case report. World J Orthop. 2021 May 18;12(5):338-345. doi: 10.5312/wjo.v12.i5.338. Li J, Wang J, Rai S, Ze R, Hong P, Wang S, Tang X. 3D-printed model and osteotomy template technique compared with conventional closing-wedge osteotomy in cubitus varus deformity. Sci Rep. 2022 Apr 26;12(1):6762. doi: 10.1038/s41598-022-10732-9. Zou M, He Y, Xu Y, Shi Q, Zeng H. Design and application of a novel 3D printing digital navigation template for cubitus varus deformity in children. Front Pediatr. 2024 Aug 7;12:1342980. doi: 10.3389/fped.2024.1342980. Hu X, Zhong M, Lou Y, Xu P, Jiang B, Mao F, Chen D, Zheng P. Clinical application of individualized 3D-printed navigation template to children with cubitus varus deformity. J Orthop Surg Res. 2020 Mar 19;15(1):111. doi: 10.1186/s13018-020-01615-8 Davids JR, Lamoreaux DC, Brooker RC, Tanner SL, Westberry DE. Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus. J Pediatr Orthop 2011;31:353-65. https://doi.org/10.1097/BPO.0b013e31821723a6. Kumar R, Rangasamy K, Raj Gopinathan N, Sudesh P, Goni VG. Is modified reverse step-cut osteotomy better than Yun's reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial. Int Orthop 2022;46:2041-53. https://doi.org/10.1007/s00264-022-05429-7. Oppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res. 1984 Sep;(188):34-9. Su Y, Nan G. Lateral closing isosceles triangular osteotomy for the treatment of a post-traumatic cubitus varus deformity in children. Bone Joint J. 2016 Nov;98-B(11):1521-1525. doi: 10.1302/0301-620X.98B11.37890. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 05 Jul, 2025 Reviewers agreed at journal 01 Jul, 2025 Reviewers invited by journal 11 Jun, 2025 Editor assigned by journal 10 Jun, 2025 Editor invited by journal 20 May, 2025 Submission checks completed at journal 20 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6595195","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470447078,"identity":"90430791-893b-4c1c-ade4-901536e70fa4","order_by":0,"name":"Mei-Ren Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDACCQjFA8SMDxgKJEjTwmzAYECCFhBgk2AwIEKH/OzmZw+/5tjImLf3Hqv4YWCRuOF2A+OHjzm4tTDOOWZuLLstjUfmzLm0mz0GEokb7hxglpy5DbcWZokEM2nJbYd5JCRyzG7wgLTcSGBj5sWjhU0i/RtQy38eCfk3ZoV/iNHCAzRc8uO2A0BbeMyYibIF6J4yacZtyTwSPDnG0jIGEsYzbyQ24/WL/Iz0bZI/t9nZS7CfMfz4pqJOtu9G8sEPH/FoAQcBDxLHsYGBsQG/eiBg/IHEsSeofBSMglEwCkYcAADB7Ep6XXRGCwAAAABJRU5ErkJggg==","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, (Guangdong P rovincial Hospital of Chinese Medicine)","correspondingAuthor":true,"prefix":"","firstName":"Mei-Ren","middleName":"","lastName":"Zhang","suffix":""},{"id":470447079,"identity":"74fcd044-d1ee-4953-90fb-6838078aeb57","order_by":1,"name":"Jian-Hao Guan","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Jian-Hao","middleName":"","lastName":"Guan","suffix":""},{"id":470447080,"identity":"f5c40a7a-bf50-4613-b8d9-84a6e037cbc8","order_by":2,"name":"Hai-Yun Chen","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Hai-Yun","middleName":"","lastName":"Chen","suffix":""},{"id":470447084,"identity":"9f104a33-3704-44b9-a7e6-c60db4fc3ab0","order_by":3,"name":"Kui Zhao","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Kui","middleName":"","lastName":"Zhao","suffix":""},{"id":470447085,"identity":"890dfb77-fdbf-4480-8930-e70771107001","order_by":4,"name":"Jian-Hui Hu","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Jian-Hui","middleName":"","lastName":"Hu","suffix":""},{"id":470447088,"identity":"0548fa6d-b77b-4b0a-abbf-5cd4da224d5d","order_by":5,"name":"Xiao Zeng","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Zeng","suffix":""},{"id":470447089,"identity":"08a3431a-8dff-4e2d-9562-f84040493977","order_by":6,"name":"Jiang-Long Guo","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Jiang-Long","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2025-05-05 14:08:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6595195/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6595195/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84717187,"identity":"05a0070c-ccdb-4df0-b1f7-ffe7129a6c39","added_by":"auto","created_at":"2025-06-16 14:29:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44519,"visible":true,"origin":"","legend":"\u003cp\u003eA. affected side of humerus (dark blue);Fig1B. the mirror image of the contralateral normal humerus (dark red);Fig1C.The proximal site of the affected humerus was superimposed onto the mirror image of the corresponding part on the contralateral, normal side;\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/6bf369e68ac543b3f51baf36.png"},{"id":84716212,"identity":"fce0c8a9-8708-49a8-82b1-162266c07592","added_by":"auto","created_at":"2025-06-16 14:21:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":210525,"visible":true,"origin":"","legend":"\u003cp\u003eA The proximal osteotomy plane (POP)roughly vertical to humerus axis and proximal about 0-1cm to the olecranon fossa，make the first osteotomy surface，Name and save the plane as the proximal osteotomy plane (POP)； Fig.2B mirror distal part of contralateral, normal side after osteotomy by the proximal osteotomy plane was superimposed onto affected side with the distal articular surface completely fitting by moving and rotating，the distal osteotomy plane (DOP) was determined by moving the proximal osteotomy plane (POP) by the correction amount. \u0026nbsp;Fig.2C-D The wedge shaped segment (orange bone) between the distal and proximal osteotomy planes was removed from the affected humerus. Fig.2E Complete the simulation of 3-D correction by moving the distal segment of the humerus to the proximal segment of the humerus. Fig.2F Verify that the overall appearance of the extremity has been appropriately corrected on the computer monitor.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/d9a4f706d8fb82c21ba2919b.png"},{"id":84715670,"identity":"1c6f575a-0ca8-48d7-b96a-9246e36cc88e","added_by":"auto","created_at":"2025-06-16 14:13:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":94251,"visible":true,"origin":"","legend":"\u003cp\u003eDesign custom-made surgical reduction guides Fig.3A-3B Four guide pins were setting placed parallel in the middle line of the lateral distal humerus while vertical to humerus axis with interval 8mm each other.The midpoint of the second and third guide pin were setting on the osteotomy surface；Fig.3C-3D.custom-made surgical reduction guides were design achievement based on the 4 guide pins and their positions while completely matching lateral side the distal humerus by solidworks software.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/a93bf144163a097712dd6885.png"},{"id":84715685,"identity":"25b82428-5fe9-4de1-802b-f51fb5217511","added_by":"auto","created_at":"2025-06-16 14:13:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":128046,"visible":true,"origin":"","legend":"\u003cp\u003eDesign custom-made surgical osteotomy guide and location guide. Fig.4A-4B custom-made surgical reduction template was separated with upper and lower parts on osteotomy plane and together with the distal humerus back to its original uncorrective place by solidworks software. Fig.4C-4D Two osteotomy slits were designed through the proximal osteotomy plane(POP) and the distal osteotomy plane(DOP) and connected with the upper and lower separated surgical reduction template respectively by a connecting rod to increase the stability of surgical osteotomy template. Fig.4E-4F surgical osteotomy template were accomplish after matching the lateral side the distal humerus by solidworks software. Fig.4G-4H. A positioning template was designed based on two guide pins upper to osteotomy plane after matching the lateral side of the distal humerus by solidworks software.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/b74c8ebac8e8ae0fdf5e12de.png"},{"id":84715683,"identity":"31dbd539-ee25-4472-8ebc-10208a8c69d8","added_by":"auto","created_at":"2025-06-16 14:13:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":94240,"visible":true,"origin":"","legend":"\u003cp\u003eScreen captures showing preoperative simulation the three-dimensional corrective osteotomy with the use of a custom-made osteotomy template combined with location and reduction template\u003c/p\u003e\n\u003cp\u003eFig.5A. location template(green ) was placed on the lateral surface of the distal part of the humerus. Fig.5B.location template was replaced by a custom-made osteotomy template and firmed fitting with another two pins through guides on osteotomy template. Fig.5C.The osteotomy was performed through the slits (arrows) on the template and the bone wedge (orange segment) was removed. Fig.5D.Deformity correction was achieved by bringing the Kirschner wires into parallel status to each other. Fig.5E.A reduction template was used to maintain the parallel position of the Kirschner wires.\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/9a870e44616d517490598f4b.png"},{"id":84716213,"identity":"29d45981-2844-4de5-be23-f2e458e334de","added_by":"auto","created_at":"2025-06-16 14:21:41","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":200328,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative simulation the three-dimensional corrective osteotomy with the use of a custom-made osteotomy template combined with location and reduction template in 3D printed model. Fig.6A.location template was placed on the lateral surface of the distal part of the humerus. Fig.6B-6C.location template was replaced by a custom-made osteotomy template and firmed fitting with another two pins through guides on osteotomy template. Fig.6D.The osteotomy was performed through the slits on the template. Fig.6E-6F.The bone wedge was removed and deformity correction was achieved by bringing the Kirschner wires into parallel position to each other. Fig.6G.A reduction template was used to maintain the parallel position of the Kirschner wires and another two Kirschner wires are inserted from the proximal pipes of the template for temporarily fixation. Fig.6H. internal fixation with lateral Locking Compression Plate (LCP) as preoperatively simulated after removing custom-made surgical osteotomy template\u003c/p\u003e\n\u003cp\u003eCase A 44 years female presented with a left cubitus varus deformity.\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/55d2d4f9692306deeb78bcd0.png"},{"id":84716210,"identity":"a0caa148-deed-4d02-bc7e-0dee806468d4","added_by":"auto","created_at":"2025-06-16 14:21:40","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":191680,"visible":true,"origin":"","legend":"\u003cp\u003eA-7C Preoperative photograph and radiographs showed cubitus varus deformity of left elbow.\u003c/p\u003e","description":"","filename":"Fig7.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/80e8ce94dc32f2c22f4d8e0f.png"},{"id":84715680,"identity":"544134fa-6c67-45a4-8e7c-ab185b5aa858","added_by":"auto","created_at":"2025-06-16 14:13:41","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":350128,"visible":true,"origin":"","legend":"\u003cp\u003eA Two 2.5mm Kirschner wires were inserted through location template pipes after all edges of the template are in exact contact with lateral surface of the distal humerus. Fig.8B location template was replaced by custom-made osteotomy template by two inserted Kirschner wires and firmed fitting with another two Kirschner wires through guides pipes on osteotomy template. Fig.8C Accurate osteotomy were completed by a saw through the osteotomy slits on custom-made osteotomy template. Fig.8D-8E.The osteotomy bone wedge was removed and deformity correction was achieved by bringing the Kirschner wires into parallel position and maintain by a reduction template，and then another Kirschner wire are inserted from pipe of the template for temporarily fixation. Fig.8G-8H. AP and lateral view fluoroscopy intraoperative showed the cubitus varus deformity was accurately corrected with internal fixation in good position. Fig.8I-8J. Passive range of-motion intraoperative immediately after surgery was normal and the cubitus varus deformity was accurately corrected. Fig8K.A about 8cm lateral incision was showed in the lateral of elbow.\u003c/p\u003e","description":"","filename":"Fig8.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/d5ab33498a33774009d6041e.png"},{"id":84715692,"identity":"b1de6248-d50b-4ad3-9113-48da8d435de7","added_by":"auto","created_at":"2025-06-16 14:13:42","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":190291,"visible":true,"origin":"","legend":"\u003cp\u003eA-9D The left elbow showed excellent function and same with normal right side two weeks postoperation. Fig.9E-9G Postoperative photograph and radiographs showed cubitus varus deformity of left elbow has been accurate corrected.\u003c/p\u003e","description":"","filename":"Fig9.png","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/2a698da0f038907c2c4c5894.png"},{"id":84719027,"identity":"a1b35db7-e6c7-404f-af87-17f370f186e8","added_by":"auto","created_at":"2025-06-16 14:45:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2425289,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6595195/v1/63b418f1-4ba1-4491-9491-03cd6de45ad8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Three-Dimensional Correction of Cubitus Varus Deformity Using Patient-Specific 3D-Printed Osteotomy Guides","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCubitus varus deformity is a common complication following a supracondylar fracture of the humerus (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Accurate correction of all three deformity components is essential to prevent long-term sequelae, including limited elbow flexion, joint instability, tardy ulnar nerve palsy, and to achieve satisfactory cosmetic results (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough various surgical methods have been proposed to correct cubitus varus deformity (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), achieving accurate correction of this complex, three-dimensional (3D) deformity remains technically challenging. The condition involves deformity in all three planes: varus angulation in the coronal plane, hyperextension in the sagittal plane, and internal rotation in the horizontal plane. As such, triplanar osteotomy techniques have been recommended to achieve comprehensive 3D correction (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), despite their associated technical demands and surgical risks (\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent advances in computer simulation and the development of custom-matched surgical guides and implants using 3D printing have addressed many of these challenges, enabling more accurate, straightforward, and safer 3D corrections (\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, differences in surgical incisions and fixation methods remain across techniques. In this study, we introduce a minimally invasive, laterally approached 3D corrective osteotomy for cubitus varus deformity, utilizing preoperative computer simulation and custom 3D-printed surgical templates. We also present clinical and radiographic outcomes of this approach.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003eBetween August 2022 and June 2025, five consecutive patients with cubitus varus deformity (Table\u0026nbsp;1)\u0026mdash;resulting from malunion of a distal humerus supracondylar fracture\u0026mdash;underwent 3D corrective osteotomy using 3D-printed, patient-matched surgical osteotomy guides, along with custom location and reduction templates. The procedure was performed through a minimally invasive lateral incision and was based on preoperative computer simulation using 3D CT models.\u003c/p\u003e \u003cp\u003eTable 1: Details of Patients for 3D corrective osteotomy for cubitus varus deformity\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"639\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003ePatient No./ Sex/Age, y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003eage at \u0026nbsp;initial injury，year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eElbow\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003eMechanism of\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInjury\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eTime From\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInjury to\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgery, mo\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eFollow-up,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003emo\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003eMEPI\u003c/p\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eoperation time,min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003eintraoperative blood loss,ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003eincreased flexion angle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eosteotomy degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eOsteotomy end union time,mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003epostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1/Fe/11\u003c/p\u003e\n \u003cp\u003e2/M/37\u003c/p\u003e\n \u003cp\u003e3/Fe/7\u003c/p\u003e\n \u003cp\u003e4/Fe/11\u003c/p\u003e\n \u003cp\u003e5/Fe/44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e336\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003cp\u003e420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e34.33\u003c/p\u003e\n \u003cp\u003e33.40\u003c/p\u003e\n \u003cp\u003e12.42\u003c/p\u003e\n \u003cp\u003e17.69\u003c/p\u003e\n \u003cp\u003e19.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eUlnar nerves injury\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e7.4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e176.8\u0026plusmn;167.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e21.6\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e139.6\u0026plusmn;22.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e42\u0026plusmn;31.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e24\u0026deg;\u0026plusmn;8 \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e23.51\u0026deg;\u0026plusmn;8.79\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;2.6\u0026plusmn;0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDetails of Patients for 3D corrective osteotomy for cubitus varus deformity\u003c/p\u003e\u003cp\u003eThe mean age at the time of initial injury was 7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94 years (range: 3\u0026ndash;11 years). All five patients (3 males and 2 females) underwent postoperative X-ray examination and were evaluated retrospectively, with a mean follow-up period of 21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 months (range: 6\u0026ndash;35 months). The mean age at the time of corrective osteotomy was 22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 years (range: 7\u0026ndash;44 years), and the mean duration from injury to surgery was 177 months (range: 8\u0026ndash;420 months). Four of the five patients had been treated with cast immobilization for the initial fracture, while one had undergone open reduction and internal fixation with Kirschner wires. All patients presented with unilateral elbow deformity and reported dissatisfaction with the cosmetic appearance of the affected limb. In addition to aesthetic concerns, three patients (Cases 1, 2, and 5) experienced restricted elbow flexion exceeding 20\u0026deg; compared with the unaffected side. No patient reported hyperextension of the elbow.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImage Acquisition and Preoperative Simulation\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStep 1: 3D Evaluation of Cubitus Varus Deformity\u003c/h2\u003e \u003cp\u003eComputerized Tomography (CT) data of both humeri were obtained, and corresponding 3D bone models were created. Scanning was performed with the forearms in maximum supination using a low-radiation dose protocol on a CT scanner (General Electric LightSpeed-640, GE, Milwaukee, WI) with a slice thickness of 0.5 mm. Three-dimensional surface models of both humeri were generated from the imaging data, and the deformity was evaluated by comparing the affected humerus with the mirrored image of the contralateral, normal side using 3D modeling software (Magics RP; Materialise, Leuven, Belgium) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u0026ndash;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).The proximal part of the affected humerus was superimposed onto the mirrored image of the corresponding area on the normal side (proximal registration) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). The same process was applied to the distal humerus (distal registration). The software calculated the 3D magnitude of deformity automatically by analyzing the transformation data required to align both the proximal and distal segments.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStep 2: Planning the 3D Corrective Osteotomy\u003c/h3\u003e\n\u003cp\u003eA simulated 3D corrective osteotomy was performed based on the deformity analysis. Two osteotomy planes were created using the software: the proximal osteotomy plane (POP) and the distal osteotomy plane (DOP). The POP was defined by positioning a virtual plane perpendicular to the humeral axis, approximately 0\u0026ndash;1 cm proximal to the olecranon fossa on the mirrored image of the normal side. This plane was saved as the POP (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).To define the DOP, the distal part of the affected humerus was aligned with the mirrored distal humerus of the normal side, and the DOP was positioned accordingly (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The wedge-shaped segment between the POP and DOP was digitally removed using the software's edit function (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). To complete the correction simulation, the distal segment of the affected humerus was repositioned to meet the proximal segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE), and the final alignment was visually verified to confirm the restored anatomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 3: Design of Patient-Specific Surgical Templates\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1) Design of the Custom-Made Surgical Reduction Template\u003c/p\u003e \u003cp\u003eThe wedge-shaped segment between the distal and proximal osteotomy planes (DOP and POP) was removed from the affected humerus. The simulation of 3D correction was completed by repositioning the distal humerus segment to align with the proximal segment. A custom reduction template was designed to fit the posterolateral surface of the corrected distal humerus.\u003c/p\u003e \u003cp\u003eFour guide pins were positioned parallel to each other along the midline of the lateral distal humerus, perpendicular to the humeral axis, with 8 mm spacing and a diameter of 2.0 or 2.5 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The midpoint between the second and third guide pins was placed on the osteotomy surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Pin spacing and diameter could be adjusted based on the patient\u0026rsquo;s bone size. The surgical reduction template was then designed using SolidWorks software based on the placement and orientation of the four guide pins (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). This template was used to assist with reduction and temporary fixation during surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e2) Design of the Custom-Made Surgical Osteotomy Template\u003c/p\u003e \u003cp\u003eThe surgical reduction template was divided into upper and lower components along the proximal osteotomy plane (POP) using the software. The distal humerus of the affected side was then returned to its original uncorrected position (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB). Two osteotomy slits were designed through the POP and DOP, each connected to the corresponding section of the reduction guide by a connecting rod to enhance template stability (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD). The final osteotomy guide plate was generated after fitting it to the lateral surface of the distal humerus using SolidWorks software (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eE\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e3) Design of the Custom-Made Location Template\u003c/p\u003e \u003cp\u003eTwo guide pins were placed proximal to the POP on the affected humerus and designated as positioning guide pins. A corresponding positioning guide plate was designed using 3D modeling software (SolidWorks) to match the lateral surface of the distal humerus (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eG\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eH).\u003c/p\u003e\n\u003ch3\u003eStep 4: Preoperative Simulation\u003c/h3\u003e\n\u003cp\u003ePreoperative simulation the 3D corrective osteotomy was conducted using computer software, incorporating the custom-made osteotomy, location, and reduction templates (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003eA-\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003eE). A corresponding 3D-printed model was also created to replicate the planned procedure (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003eA-\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003eH).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStep 5: Surgical Technique\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eCase Presentation\u003c/h2\u003e \u003cp\u003eA 44-year-old female sustained a supracondylar fracture of the left humerus at the age of nine. She was treated with immobilization using a cast; however, the cubitus varus deformity persisted for 35 years after the injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e7\u003c/span\u003eA). A 3D evaluation of the deformity, based on comparison with the mirrored image of the normal contralateral side, revealed the following: 27\u0026deg; of varus, 0\u0026deg; of extension, and 10\u0026deg; of internal rotation deformity (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e7\u003c/span\u003eB\u0026ndash;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e7\u003c/span\u003eC). The preoperative carrying angles (CA) of the normal and affected sides were 13.8\u0026deg; and \u0026minus;\u0026thinsp;13.4\u0026deg;, respectively. The preoperative tilting angles (TA) were 52\u0026deg; and 39\u0026deg;, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe distal part of the humerus was exposed through a lateral approach (8cm incision) with the patient in the supine position. Two 2.5 mm Kirschner wires were inserted through the location guide once the guide edges were in full contact with the lateral humeral surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eA). The location guide was then replaced with a custom-made surgical osteotomy template secured by the same wires. Two additional 2.5 mm Kirschner wires were inserted through the remaining guide channels to ensure firm contact with the bone surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOsteotomy was performed using a saw through the slits in the guide (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eC), followed by removal of the wedge-shaped bone segment. The correction was achieved by aligning the four Kirschner wires in parallel and securing them temporarily using the reduction template, which fit snugly against the bone surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eD). Another Kirschner wire was inserted through the reduction guide to stabilize the reduction (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eE). For patients with closed physes, internal fixation was performed using a lateral locking compression plate (LCP), as planned preoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eF). The lateral Kirschner wire was removed while the medial one was retained. Alignment was confirmed intraoperatively with C-arm fluoroscopy (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eG\u0026ndash;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eH).\u003c/p\u003e \u003cp\u003eImmediately after surgery, the passive range of motion was normal, and the deformity was successfully corrected through the 8 cm lateral incision (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eI\u0026ndash;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e8\u003c/span\u003eK).\u003c/p\u003e \u003cp\u003eBoth active and passive range-of-motion exercises were started the day after surgery without the use of a splint. Two weeks postoperatively, elbow flexion improved from 120\u0026deg; to 145\u0026deg; and extension from 10\u0026deg; to 0\u0026deg;. Pronation and supination of the forearm also returned to normal (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e9\u003c/span\u003eA\u0026ndash;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e9\u003c/span\u003eD). The carrying and tilting angles were corrected to 6.3\u0026deg; and 48\u0026deg;, respectively. Photographs and anteroposterior/lateral radiographs confirmed accurate correction of the deformity in the left elbow (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e9\u003c/span\u003eG\u0026ndash;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e9\u003c/span\u003eI).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean carrying angle and tilting angle on the affected side improved significantly from \u0026minus;\u0026thinsp;15.74\u0026deg; \u0026plusmn; 6.58\u0026deg; (varus) and 54.8\u0026deg; \u0026plusmn; 7.40\u0026deg;, respectively, before surgery, to 7.77\u0026deg; \u0026plusmn; 3.94\u0026deg; (valgus) and to 51.4\u0026deg; \u0026plusmn; 2.33\u0026deg;, respectively, after surgery(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The elbow range of motion returned to normal, with an increase in flexion angle of 24\u0026deg; \u0026plusmn; 8\u0026deg; (range: 15\u0026deg;\u0026ndash;35\u0026deg;). Hyperextension of the elbow and internal rotation of the shoulder were normalized in all patients. Bone union was achieved at a mean of 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 months (range: 2\u0026ndash;3 months) after surgery. Operation time averaged 139.6\u0026thinsp;\u0026plusmn;\u0026thinsp;22.26 minutes (range: 116\u0026ndash;175 minutes), and mean intraoperative blood loss was 42\u0026thinsp;\u0026plusmn;\u0026thinsp;31.87 mL (range: 10\u0026ndash;100 mL). The mean osteotomy correction achieved was 23.51\u0026deg; \u0026plusmn; 8.79\u0026deg; (range: 12.43\u0026deg;\u0026ndash;33.43\u0026deg;).According to the MEPI (Mayo Elbow Performance Index) assessment, all five patients had excellent outcomes at the final follow-up (mean: 21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 months), and none had poor results. No patient experienced a recurrence of the varus deformity. No wound-related complications occurred, although one patient showed evidence of neurovascular injury involving the ulnar nerve. No patients reported prominence of the lateral humerus.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e pre- and postoperative carrying angles and Tiling Angle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eRadiographic Parameters\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRadiographic Parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eClinical Parameters\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCarrying Angle (deg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTiling Angle (deg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreop.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostop.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal Side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePreop.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePostop.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNormal Side\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-22.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-22.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-4.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-16.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-13.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-15.74\u0026thinsp;\u0026plusmn;\u0026thinsp;6.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.17\u0026thinsp;\u0026plusmn;\u0026thinsp;5.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn adolescents, Cubitus varus deformity is the most common complication following distal humeral fractures (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Recent studies have demonstrated that cubitus varus is a 3D deformity involving not only varus angulation but also extension and internal rotation of the distal humeral segment (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). As a result, corrective approaches have increasingly focused on 3D techniques to achieve comprehensive improvements in function and appearance (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). However, accurately correcting angular deformities in all three planes remains technically challenging for surgeons. It often requires repeated intraoperative adjustments or visual estimation, which may lead to substantial deviations from the desired alignment and suboptimal outcomes (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent advances in computer simulation technology, along with the use of patient-specific surgical guides and implants created through 3D printing, have addressed many of the challenges associated with correcting cubitus varus deformity. These technologies have enabled accurate, simple, and safe 3D osteotomy procedures (\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Several studies have reported excellent outcomes and improved osteotomy accuracy, leading many authors to recommend this technique as an ideal treatment approach for cubitus varus deformity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor example, Jiang et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) reported that the combined rate of excellent and good outcomes was 92.3%. Takeyasu et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) described the use of custom-made osteotomy templates in 30 cases of cubitus varus deformity, with 90% of patients achieving excellent results and the remaining 10% achieving good results. However, compared with conventional procedures, 3D-guided osteotomy often requires a larger surgical field to accommodate the guide. Sri-Utenchai et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) used a standard posterior paratricipital approach with a 20-cm posterior midline incision. Zhang et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) reported the use of double incisions (medial and lateral) in their study. Omori et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) used a lateral approach in 7 cases and a posterior approach in 10 cases, though incision lengths were not specified. Takeyasu et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) also used a lateral approach but did not report incision length.\u003c/p\u003e \u003cp\u003eIn this study, we applied a 3D-printed, patient-specific surgical osteotomy template combined with location and reduction guides to perform accurate 3D corrective osteotomy for cubitus varus deformity through a minimal lateral incision. All patients achieved excellent outcomes, including improved cosmetic appearance, no loss of correction, and no delayed or nonunion at the osteotomy site.\u003c/p\u003e \u003cp\u003eThere are several reasons why a single, small lateral incision was sufficient to achieve accurate 3D correction in our cases. First, we used a conventional closed lateral wedge osteotomy. An 8 cm lateral incision was sufficient to allow the osteotomy template to be properly attached to the lateral surface of the distal humerus.\u003c/p\u003e \u003cp\u003eSecond, although our osteotomy template was relatively larger than those used in some previous studies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), we designed and added a location template that was smaller than the main guide. Two location Kirschner wires were accurately inserted using this smaller guide through the 8 cm incision. Afterward, the smaller guide was replaced with the larger osteotomy template without requiring additional incision length. This method ensured a secure fit and prevented loosening or shifting of the guide during osteotomy, thereby improving surgical precision.\u003c/p\u003e \u003cp\u003eThird, the reduction guide was specifically designed to assist with post-osteotomy alignment by temporarily holding the four Kirschner wires in a parallel position. This not only ensured an accurate reduction without extending the original incision but also significantly shortened the reduction time. Using this technique, all five patients achieved single-attempt osteotomy success. Postoperative appearance and correction angles matched the preoperative plan and bone healing was confirmed at the osteotomy site approximately three months after surgery.\u003c/p\u003e \u003cp\u003eHowever, several practical considerations should be noted when applying this technique clinically. First, the cutting slits on the osteotomy template were prone to breakage due to oscillation of the bone saw during the procedure, particularly when the slit thickness was insufficient. To address this, we increased the thickness of the cutting slits to at least 3 mm and prepared two surgical guides for each case, both of which were sterilized prior to surgery.\u003c/p\u003e \u003cp\u003eOne patient developed ulnar nerve paralysis postoperatively due to the placement of the medial Kirschner wire. The nerve function fully recovered after immediate wire removal and four weeks of treatment with neurotrophic agents. Following this event, we began using a 1 cm incision over the medial epicondyle to expose the entry point for the medial Kirschner wire directly, and no further ulnar nerve injuries occurred.\u003c/p\u003e \u003cp\u003eSeveral practical considerations should be noted when applying this technique clinically. First, the cutting slits on the osteotomy template were prone to breakage due to oscillation of the bone saw during the procedure, particularly when the slit thickness was insufficient. To address this issue, we increased the slit thickness to at least 3 mm and prepared two surgical guides per case, both of which were sterilized prior to surgery. One patient developed ulnar nerve paralysis postoperatively due to the placement of the medial Kirschner wire. The nerve function fully recovered after immediate wire removal and four weeks of treatment with neurotrophic agents. Following this event, we began using a 1 cm incision over the medial epicondyle to directly expose the Kirschner wire entry point, and no further ulnar nerve injuries were observed. Although previous reports have described limitations of 3D-printed guide plates, such as a risk of correction loss due to reduced bone contact area and compromised fixation stability (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), our study did not observe these issues.\u003c/p\u003e \u003cp\u003eThere were no cases of correction loss, delayed union, nonunion, or fixation failure in our study. This may be attributed to the use of lateral LCP plate fixation combined with medial pinning, which provided sufficient stability for early active functional exercise after surgery. Radiation exposure from CT imaging is another concern (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), but this can be minimized through low-dose imaging protocols and improved image-processing technologies. A commonly cited disadvantage of 3D printing is the requirement for additional equipment and software for simulation and model generation. However, our team handled all design and printing in-house, which significantly reduced both production time and cost. Previous studies have also suggested that patient-specific guides may reduce the risk of revision surgery by lowering complication rates and overall medical expenses. Finally, this was a retrospective, non-randomized study with a limited sample size and a relatively short follow-up period, which may introduce subjective bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e3D-printed, patient-specific surgical osteotomy guides\u0026mdash;combined with location and reduction templates\u0026mdash;enable simple, safe, and accurate 3D correction of cubitus varus deformity through a small lateral incision. Based on computer simulation, this surgical technique is highly reproducible and may help minimize differences in surgeon skill. It may serve as a viable therapeutic option for correcting cubitus varus deformity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki.The patient agreed to participate in this study. Informed consent was obtained from the patient\u0026nbsp;or the patient\u0026apos;s and legal guardian\u0026nbsp;prior to the study. This study was approved by Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patients\u0026nbsp;or the patient\u0026apos;s and legal guardian for publication of this study and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe data used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eAll Authors declared no benefits in any form have been, or will be received, from any commercial party related directly, or indirectly, to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e2024 Science and Technology Innovation Bureau of Zhuhai city（number ZH22036201210076PWC）were received in support of this study. No benefits in any form have been, or will be received, from any commercial party related directly, or indirectly, to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eMei-Ren Zhang designed the study and wrote the manuscript.\u0026nbsp;Jian-Hao Guan, Hai-Yun Chen\u0026nbsp;and\u0026nbsp;Kui-Zhao,Jian-Hui Hu\u0026nbsp;were involved in the treatment. Xiao Zeng performed literature review.Jiang-long Guo\u0026nbsp;performed data collection and processing，All authors contributed to writing the manuscript. All authors read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDevnani AS. Late presentation of supracondylar fracture of the humerus in children. 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J Hand Surg Br. 1986 Oct;11(3):352-6. doi: 10.1016/0266-7681(86)90156-7.\u003c/li\u003e\n\u003cli\u003eAbe M, Ishizu T, Shirai H, Okamoto M, Onomura T. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg Am. 1995 Jan;20(1):5-9. doi: 10.1016/S0363-5023(05)80047-4.\u003c/li\u003e\n\u003cli\u003eJeon IH, Oh CW, Kyung HS, Park IH, Kim PT. Tardy ulnar nerve palsy in cubitus varus deformity associated with ulnar nerve dislocation in adults. J Shoulder Elbow Surg. 2006 Jul-Aug;15(4):474-8. doi: 10.1016/j.jse.2005.10.009. \u003c/li\u003e\n\u003cli\u003eMitsunari A, Muneshige H, Ikuta Y, Murakami T. Internal rotation deformity and tardy ulnar nerve palsy after supracondylar humeral fracture. J Shoulder Elbow Surg. 1995 Jan-Feb;4(1 Pt 1):23-9. doi: 10.1016/s1058-2746(10)80004-7.\u003c/li\u003e\n\u003cli\u003eLaupattarakasem W, Mahaisavariya B, Kowsuwon W, Saengnipanthkul S. Pentalateral osteotomy for cubitus varus. Clinical experiences of a new technique. J Bone Joint Surg Br. 1989 Aug;71(4):667-70. doi: 10.1302/0301-620X.71B4.2768319.\u003c/li\u003e\n\u003cli\u003eUsui M, Ishii S, Miyano S, Narita H, Kura H. Three-dimensional corrective osteotomy for treatment of cubitus varus after supracondylar fracture of the humerus in children. J Shoulder Elbow Surg. 1995 Jan-Feb;4(1 Pt 1):17-22. doi: 10.1016/s1058-2746(10)80003-5.\u003c/li\u003e\n\u003cli\u003eMurase T, Oka K, Moritomo H, Goto A, Yoshikawa H, Sugamoto K. Three-dimensional corrective osteotomy of malunited fractures of the upper extremity with use of a computer simulation system. J Bone Joint Surg Am. 2008 Nov;90(11):2375-89. doi: 10.2106/JBJS.G.01299.\u003c/li\u003e\n\u003cli\u003eSrivastava AK, Srivastava D, Gaur S. Lateral closed wedge osteotomy for cubitus varus deformity. Indian J Orthop. 2008 Oct;42(4):466-70. doi: 10.4103/0019-5413.43397.\u003c/li\u003e\n\u003cli\u003eD prF. Chung MS, Baek GH. Three-dimensional corrective osteotomy for cubitus varus in adults. J Shoulder Elbow Surg 2003;12:472-5. https://doi.org/10.1016/s1058-2746(03)00090-9.\u003c/li\u003e\n\u003cli\u003eBauer AS, Pham B, Lattanza LL. Surgical correction of cubitus varus. J Hand Surg Am 2016;41:447-52. https://doi.org/10.1016/j.jhsa.2015.12.019\u003c/li\u003e\n\u003cli\u003eOppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res 1984:34-9.\u003c/li\u003e\n\u003cli\u003eSu Y, Xie Y, Nan G. A novel method of lateral closing wedge osteotomy for cubitus varus deformity in children. BMC Surg 2022;22:408. https://doi.org/10.1186/s12893-022-01854-y.\u003c/li\u003e\n\u003cli\u003eTakagi T, Takayama S, Nakamura T, Horiuchi Y, Toyama Y, Ikegami H. Supracondylar osteotomy of the humerus to correct cubitus varus: do both internal rotation and extension deformities need to be corrected? J Bone Joint Surg Am 2010;92:1619-26. https://doi.org/10.2106/jbjs.I.00796\u003c/li\u003e\n\u003cli\u003eZhang YW, Xiao X, Gao WC, Xiao Y, Zhang SL, Ni WY, Deng L. Efficacy evaluation of three-dimensional printing assisted osteotomy guide plate in accurate osteotomy of adolescent cubitus varus deformity. J Orthop Surg Res. 2019 Nov 9;14(1):353. doi: 10.1186/s13018-019-1403-7.\u003c/li\u003e\n\u003cli\u003eJiang H, Li M, Wu Y. Application of computer simulation in the treatment of traumatic cubitus varus deformity in children. Medicine (Baltimore). 2019 Jan;98(1):e13882. doi: 10.1097/MD.0000000000013882.\u003c/li\u003e\n\u003cli\u003eMurase T, Takeyasu Y, Oka K, Kataoka T, Tanaka H, Yoshikawa H. Three dimensional corrective osteotomy for cubitus varus deformity with use of custom-made surgical guides. JBJS Essent Surg Tech 2014;4:e6. https://doi.org/ 10.2106/jbjs.St.M.00044\u003c/li\u003e\n\u003cli\u003eOka K, Tanaka H, Okada K, Sahara W, Myoui A, Yamada T, et al. Three dimensional corrective osteotomy for malunited fractures of the upper extremity using patient-matched instruments: a prospective, multicenter, open-label, single-arm trial. J Bone Joint Surg Am 2019;101:710-21. https:// doi.org/10.2106/jbjs.18.00765\u003c/li\u003e\n\u003cli\u003eTakeyasu Y, Oka K, Miyake J, Kataoka T, Moritomo H, Murase T. Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device. J Bone Joint Surg Am. 2013 Nov 20;95(22):e173. doi: 10.2106/JBJS.L.01622.\u003c/li\u003e\n\u003cli\u003eHo CA. Cubitus Varus-It\u0026apos;s More Than Just a Crooked Arm! J Pediatr Orthop. 2017 Sep;37 Suppl 2:S37-S41. doi: 10.1097/BPO.0000000000001025.\u003c/li\u003e\n\u003cli\u003eGorelick L, Robinson D, Loberant N, Rozano-Gorelick A, Yassin M, Garti A, Ram E. Assessment of the normal and pathological alignment of the elbow in children using the trochleocapitellar index. BMC Musculoskelet Disord. 2014 Feb 27;15:60. doi:10.1186/1471-2474-15-60.\u003c/li\u003e\n\u003cli\u003eOmori S, Murase T, Oka K, Kawanishi Y, Oura K, Tanaka H, Yoshikawa H. Postoperative accuracy analysis of three-dimensional corrective osteotomy for cubitus varus deformity with a custom-made surgical guide based on computer simulation. J Shoulder Elbow Surg. 2015 Feb;24(2):242-9. doi: 10.1016/j.jse.2014.08.020. Epub 2014 Oct 25.\u003c/li\u003e\n\u003cli\u003eNorth D, Held M, Dix-Peek S, Hoffman EB. French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years. J Pediatr Orthop. 2016 Jan;36(1):19-24. doi: 10.1097/BPO.0000000000000405.\u003c/li\u003e\n\u003cli\u003eTanwar YS, Habib M, Jaiswal A, Singh S, Arya RK, Sinha S. Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note. J Shoulder Elbow Surg. 2014 Nov;23(11):1612-7. doi: 10.1016/j.jse.2014.06.030. Epub 2014 Sep 17.\u003c/li\u003e\n\u003cli\u003eTakeyasu Y, Murase T, Miyake J, Oka K, Arimitsu S, Moritomo H, et al. Three-dimensional analysis of cubitus varus deformity after supracondylar fractures of the humerus. J Shoulder Elbow Surg. 2011;20:440\u0026ndash;8. https://doi.org/10.1016/j.jse.2010.11.020\u003c/li\u003e\n\u003cli\u003eBovid KM, Kohler EJ, Habeck JM, Gustafson PA. Utilization of a 3D-printed model for preoperative planning and operative osteotomy of a pediatric cubitus varus deformity. JSES Open Access. 2019 Aug 9;3(3):219-224. doi: 10.1016/j.jses.2019.05.003.\u003c/li\u003e\n\u003cli\u003eOka K, Murase T, Okada K, Tanaka H, Yoshikawa H. Single-plane rotational osteotomy for cubitus varus deformity based on preoperative computer simulation. J Orthop Sci. 2019 Sep;24(5):945-951. doi: 10.1016/j.jos.2017.04.012. Epub 2017 May 21.\u003c/li\u003e\n\u003cli\u003eSri-Utenchai N, Pengrung N, Srikong K, Puncreobutr C, Lohwongwatana B, Sa-Ngasoongsong P. Three-dimensional printing technology for patient-matched instrument in treatment of cubitus varus deformity: A case report. World J Orthop. 2021 May 18;12(5):338-345. doi: 10.5312/wjo.v12.i5.338. \u003c/li\u003e\n\u003cli\u003eLi J, Wang J, Rai S, Ze R, Hong P, Wang S, Tang X. 3D-printed model and osteotomy template technique compared with conventional closing-wedge osteotomy in cubitus varus deformity. Sci Rep. 2022 Apr 26;12(1):6762. doi: 10.1038/s41598-022-10732-9.\u003c/li\u003e\n\u003cli\u003eZou M, He Y, Xu Y, Shi Q, Zeng H. Design and application of a novel 3D printing digital navigation template for cubitus varus deformity in children. Front Pediatr. 2024 Aug 7;12:1342980. doi: 10.3389/fped.2024.1342980.\u003c/li\u003e\n\u003cli\u003eHu X, Zhong M, Lou Y, Xu P, Jiang B, Mao F, Chen D, Zheng P. Clinical application of individualized 3D-printed navigation template to children with cubitus varus deformity. J Orthop Surg Res. 2020 Mar 19;15(1):111. doi: 10.1186/s13018-020-01615-8\u003c/li\u003e\n\u003cli\u003eDavids JR, Lamoreaux DC, Brooker RC, Tanner SL, Westberry DE. Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus. J Pediatr Orthop 2011;31:353-65. https://doi.org/10.1097/BPO.0b013e31821723a6.\u003c/li\u003e\n\u003cli\u003eKumar R, Rangasamy K, Raj Gopinathan N, Sudesh P, Goni VG. Is modified reverse step-cut osteotomy better than Yun\u0026apos;s reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial. Int Orthop 2022;46:2041-53. https://doi.org/10.1007/s00264-022-05429-7.\u003c/li\u003e\n\u003cli\u003eOppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res. 1984 Sep;(188):34-9.\u003c/li\u003e\n\u003cli\u003eSu Y, Nan G. Lateral closing isosceles triangular osteotomy for the treatment of a post-traumatic cubitus varus deformity in children. Bone Joint J. 2016 Nov;98-B(11):1521-1525. doi: 10.1302/0301-620X.98B11.37890.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cubitus varus deformity, three-dimensional printing, custom-matched surgical osteotomy template, reduction templates, accurate osteotomy","lastPublishedDoi":"10.21203/rs.3.rs-6595195/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6595195/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eVarious three-dimensional (3D) corrective osteotomy techniques have been reported for the treatment of cubitus varus deformity. However, achieving accurate correction through a minimally invasive incision remains technically challenging. This study introduces a method for accurate 3D osteotomy of cubitus varus deformity using a minimally invasive lateral incision.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eFive patients (2 males and 3 females) with cubitus varus deformity following supracondylar fracture underwent 3D corrective osteotomy using 3D-printed, patient-specific osteotomy templates, along with custom location and reduction guides, between August 2022 and January 2025. These cases were evaluated retrospectively. Clinical outcomes assessed included pre- and postoperative carrying angles, operative time, elbow joint function, intraoperative blood loss, degree of osteotomy, time to bone union, and postoperative complications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe mean carrying angle on the affected side improved significantly from \u0026minus;\u0026thinsp;15.74\u0026deg; \u0026plusmn; 6.58\u0026deg; (varus) preoperatively to 7.77\u0026deg; \u0026plusmn; 3.94\u0026deg; (valgus) postoperatively. The mean tilting angle improved from 54.8\u0026deg; \u0026plusmn; 7.40\u0026deg; to 51.4\u0026deg; \u0026plusmn; 2.33\u0026deg;. Elbow range of motion normalized in all patients, with a mean increase in flexion angle of 24\u0026deg; \u0026plusmn; 8\u0026deg; (range: 15\u0026deg;\u0026ndash;35\u0026deg;). Hyperextension of the elbow and internal rotation of the shoulder were also corrected. Bone union was achieved at a mean of 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 months (range: 2\u0026ndash;3 months). The average operative time was 139.6\u0026thinsp;\u0026plusmn;\u0026thinsp;22.26 minutes (range: 116\u0026ndash;175 minutes), and mean intraoperative blood loss was 42\u0026thinsp;\u0026plusmn;\u0026thinsp;31.87 mL (range: 10\u0026ndash;100 mL). The mean correction angle achieved through osteotomy was 23.51\u0026deg; \u0026plusmn; 8.79\u0026deg; (range: 12.43\u0026deg;\u0026ndash;33.43\u0026deg;). According to the Mayo Elbow Performance Index (MEPI), all five patients achieved excellent outcomes at the final follow-up (mean: 21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 months), with no reports of poor results, recurrence of varus deformity, or wound-related complications. One patient exhibited transient ulnar nerve symptoms postoperatively. No patients reported prominence of the lateral humerus.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe use of a 3D-printed, patient-specific osteotomy guide combined with custom location and reduction templates enables safe, accurate, and reproducible 3D correction of cubitus varus deformity through a minimally invasive lateral incision. This surgical technique, grounded in 3D computer simulation, reduces variability between surgeons and may represent a viable therapeutic option for the correction of cubitus varus deformity.\u003c/p\u003e","manuscriptTitle":"Three-Dimensional Correction of Cubitus Varus Deformity Using Patient-Specific 3D-Printed Osteotomy Guides","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 14:13:34","doi":"10.21203/rs.3.rs-6595195/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-06T02:48:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123980463742928635963810240706613348734","date":"2025-07-02T02:56:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T12:52:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T06:30:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T13:06:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T09:25:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-05-20T09:24:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a51046c0-fd79-4520-88c4-deaed4baab69","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T14:13:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 14:13:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6595195","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6595195","identity":"rs-6595195","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}