3D Accurate Osteotomy for Pediatric Cubitus Varus Deformity using a Custom-Matched Surgical Osteotomy Template Combined with a Reduction Template via a Limited Lateral Incision: A Case Report and Literature Review

3D Accurate Osteotomy for Pediatric Cubitus Varus Deformity using a Custom-Matched Surgical Osteotomy Template Combined with a Reduction Template via a Limited Lateral Incision: A Case Report and Literature Review | 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 Case Report 3D Accurate Osteotomy for Pediatric Cubitus Varus Deformity using a Custom-Matched Surgical Osteotomy Template Combined with a Reduction Template via a Limited Lateral Incision: A Case Report and Literature Review Mei-Ren ZHANG, Jian-Hao Guan, Hai-Yun CHEN, Kui Zhao, Xiao Zeng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6856636/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cubitus varus deformity is a common complication following a supracondylar fracture of the humerus in children. Due to the limited capacity of the distal humeral epiphysis to spontaneously correct existing varus deformity, this condition typically persists into adulthood without improvement. Accurate correction of this deformity is essential to prevent late sequelae and significantly enhance cosmetic appearance. However, achieving precise correction through a limited incision is technically challenging. Case Presentation: We present the case of a 12-year-old female who sustained a supracondylar fracture of the left humerus after a fall when she was 11 years old. The patient was initially treated with an immobilization cast at another hospital. Four weeks after cast removal, a cubitus varus deformity was noted, and it persisted for 8 months following the initial injury. The patient was then referred to our hospital seeking complete functional and cosmetic improvement. The patient underwent a three-dimensional (3D) accurate osteotomy using a custom-made surgical template combined with a reduction template via a limited lateral incision. The operation time was 116 minutes, with an intraoperative blood loss of 20 mL. The carrying angle and tilting angle on the affected side improved significantly from − 22.1° (varus) and 1.3° preoperatively to 12.2° (valgus) and 52.3°, respectively, postoperatively. Bone union was achieved at 3 months after surgery. At the one-year follow-up, the patient had an excellent outcome with a Hospital for Special Surgery score of 98, and without recurrence of the varus deformity, neurovascular injury, or wound complications. Conclusion: Accurate 3D correction of pediatric cubitus varus deformity can be successfully achieved using a custom-matched surgical osteotomy template combined with a reduction template via a limited lateral incision. pediatric cubitus varus deformity 3D accurate osteotomy custom-matched surgical osteotomy template limited lateral incision Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Cubitus varus deformity is a common complication following supracondylar humeral fractures in children 3 , 8 , 14 , 23 . Various methods for three-dimensional (3D) corrective osteotomy have been reported 9 , 11 , 18 , 22 . However, these methods differ regarding surgical incisions and internal fixation techniques, and achieving accurate osteotomy through a minimal incision remains technically challenging. Cubitus varus deformity involves three planes: varus in the coronal plane, overextension in the sagittal plane, and internal rotation in the horizontal plane. Here, we introduce a 3D preoperative computer simulation-based approach using custom-printed surgical templates to achieve accurate 3D osteotomy via a limited lateral incision, and we review the relevant literature. Case presentation A 12-year-old female presented to our hospital with concerns regarding the cosmetic appearance of her left elbow and limited elbow joint function, eight months after sustaining a supracondylar fracture of the humerus. The patient had been treated initially with an immobilization cast for four weeks, after which the cubitus varus deformity persisted, becoming obvious to her parents. Preoperative photographs and anteroposterior (AP) and lateral X-rays confirmed cubitus varus deformity of the left elbow. The preoperative carrying angles of the normal and affected sides were 15.3° and − 22.1° (varus), respectively, and the tilting angles (TA) were 52.1° and 1.3°, respectively. The elbow's range of motion had returned to a normal range (0°–120°), but showed a 30° limitation compared with the unaffected side. Hyperextension of the elbow and internal rotation of the shoulder were normalized. The patient underwent 3D accurate osteotomy using a custom-made 3D printed surgical template combined with a reduction template via a limited lateral incision. Informed consent was obtained from the patient and her parents prior to publication of this case report. Surgery Treatment Step 1: 3D Evaluation of Cubitus Varus Deformity and Planning of the 3D Corrective Osteotomy Both humerus were scanned with the forearms in maximum supination using a CT scanner (Computerized Tomography General Electric LightSpeed-640, GE, Milwaukee, WI) with a low-radiation dose technique. We created 3D bone-surface models of both humerus from digital data and evaluated the deformity three-dimensionally by comparing the affected humerus to a mirror image of the contralateral normal humerus using specialized 3D software (Magics RP; Materialise, Leuven, Belgium) (Fig. 1 A- 1 B). The affected humerus was superimposed onto the mirror image of the corresponding part on the contralateral normal side (proximal registration) by translating and rotating the two humeral models until they matched precisely (Fig. 1 C). The computer software automatically calculated the 3D deformity based on the transformation data from distal and proximal registration (Fig. 1 D). A simulated 3D corrective osteotomy was then performed based on the deformity evaluation data. With the proximal portion of the affected humerus aligned to the mirror image of the contralateral normal side, we placed an osteotomy plane approximately parallel to the distal articular surface and just proximal (0–1 cm) to the olecranon fossa, naming and saving this as the distal osteotomy plane (DOP) (Fig. 2 A). Next, the distal humerus from the normal side was precisely superimposed onto the distal part of the affected side by translation and rotation, and the proximal osteotomy plane (POP) was established by shifting the distal osteotomy plane according to the amount of required correction (Fig. 2 B). The wedge-shaped segment defined by the DOP and POP was then removed from the affected humerus using the software’s editing function (Fig. 2 C- 2 D). The simulation of 3D correction was completed by moving the distal humerus segment to align with the proximal segment (Fig. 2 E). Finally, we verified on the computer monitor that the overall appearance of the extremity had been correctly restored (Fig. 2 F). Step 2: Design of Patient-Specific Surgical Guides (Including Surgical Osteotomy and Reduction Templates) 1) Design of the Custom-Made Surgical Reduction Template The wedge-shaped segment defined by the DOP and POP was removed from the affected humerus. The simulation of the 3D correction was completed by aligning the distal humerus segment to the proximal humerus segment. The reduction guide was shaped to precisely fit the posterolateral surface of the distal humerus after the 3D correction was simulated. Four guide pins (2.0 mm diameter each) were placed parallel to each other, spaced at intervals of 8 mm along the midline of the lateral distal humerus, perpendicular to the humeral axis (Fig. 3 A). The midpoint between the second and third guide pins was placed directly on the osteotomy surface (Fig. 3 B). Using SolidWorks software, the custom-made surgical reduction guide was then designed based on these four guide pins and their exact positions, ensuring it precisely matched the lateral side of the distal humerus (Fig. 3 C- 3 D). This guide was designed to facilitate accurate reduction and temporary fixation following osteotomy. 2) Design of the Custom-Made Surgical Osteotomy Template The custom-made surgical reduction guide was divided into upper and lower parts at the osteotomy surface using the software, and the distal humerus of the affected side was returned to its original uncorrected position (Fig. 3 E). Two osteotomy slits were designed along the POP and the DOP, each connected to the upper and lower sections of the surgical reduction guide by a connecting rod, enhancing the stability of the surgical osteotomy guide (Fig. 3 F). The osteotomy guide was finalized by precisely matching it to the lateral side of the distal humerus using SolidWorks software (Fig. 3 G). A preoperative simulation of the 3D corrective osteotomy was conducted using the custom-made osteotomy template combined with the reduction template on a 3D-printed model (Fig. 4 A- 4 F). Step 3: Surgical Technique The patient underwent osteotomy for cubitus varus deformity (Fig. 5 A- 5 C) using the custom-made surgical template combined with the reduction template via a limited lateral incision under general anesthesia, and was positioned supine. A tourniquet was routinely applied and inflated to 200 mmHg. A limited lateral incision extending from 6 cm proximal to 2 cm distal to the elbow crease was made without exposure of the radial nerve. Four 2.0 mm Kirschner wires were inserted through guide pipes on the custom-made surgical osteotomy template after all edges of the guide were confirmed to be in complete contact with the lateral surface of the distal humerus (Fig. 6 A). Osteotomy was performed using a saw guided by the cutting slits in the osteotomy template (Fig. 6 B). The wedge-shaped bone segment was then removed (Fig. 6 C). The planned correction was achieved by aligning the four Kirschner wires parallel to each other and securing them temporarily with the reduction template, ensuring complete contact with the bone surface; subsequently, an additional three Kirschner wires were inserted for temporary fixation (Fig. 6 D- 6 E). Internal fixation was performed using a lateral Locking Compression Plate (LCP) after removing the reduction template; lateral Kirschner wires were then removed while medial Kirschner wires were retained percutaneously. Alignment was confirmed intraoperatively using C-arm fluoroscopy. The passive range of motion immediately after surgery was normal, and the cubitus varus deformity was corrected through an 8 cm lateral incision (Fig. 6 F- 6 H). The periosteum was sutured, and the skin was closed without drainage. Total operative time was 116 minutes, with intraoperative blood loss of 20 mL. Result AP and lateral X-rays demonstrated accurate correction of the cubitus varus deformity of the left elbow. The carrying angle and tilting angle on the affected side significantly improved from − 22.1° (varus) (Fig. 6 I) and 1.3° (Fig. 6 J) preoperatively, to 12.2° (valgus) (Fig. 6 K) and 52.3° (Fig. 6 L), respectively, postoperatively, closely matching the contralateral normal side (Fig. 6 M- 6 N). Active and passive range-of-motion exercises were permitted on the day following surgery without splint protection. Medial Kirschner wires were removed two months postoperatively, and complete bone union was achieved three months after surgery. The patient underwent reoperation for asymptomatic hardware removal and had a full range of motion (Fig. 7 A- 7 E), good strength, and returned to her previous level of sporting activity. The patient had an excellent outcome according to the Hospital for Special Surgery score, without recurrence of varus deformity, neurovascular injury, or wound complications. Photographs and AP and lateral X-rays confirmed accurate correction of the cubitus varus deformity of the left elbow at the one-year follow-up (Fig. 7 G- 7 I). Discussion Cbitus varus deformity is the most common complication of distal humeral fractures in adolescents 24 . Recent studies have demonstrated that cubitus varus deformity is a 3D deformity involving not only varus angulation but also extension and internal rotation of the distal humeral segment 1 , 4 , 5 . Nevertheless, 3D correction has increasingly become the focus of surgical treatment, aiming for complete improvement in both appearance and function 13 , 17 , 19 – 21 . Despite the importance of 3D correction, accurately achieving the desired correction of each dimension during surgery remains technically challenging. Surgeons often require repeated adjustments or relying solely on general appearance for guidance, increasing the risk of residual deformity 24 . Recent advances in computer simulation technology, patient-matched surgical guides, and 3D printing have addressed these challenges, enabling accurate, simple, and safe 3D correction 7 , 12 , 16 , 20 , 24 . These technologies allow for precise preoperative planning and accurate intraoperative execution. Several authors have reported excellent outcomes with improved accuracy in osteotomy using 3D technology, and they have recommended this approach as an ideal treatment for cubitus varus deformity 2 , 16 , 17 , 20 , 24 . However, compared with conventional procedures, corrective osteotomy using 3D surgical templates may require a larger surgical field or incision position the template. For example, Sri-Utenchai 10 . used a standard posterior paratricipital approach with a 20-cm posterior midline incision. Similarly, Zhang et al 24 reported using a double-incision approach with routine medial and lateral incisions. These approaches ensure accurate correction but at the cost of greater soft tissue exposure. In contrast, we achieved accurate 3D corrective osteotomy of cubitus varus deformity using a single limited lateral incision. Our approach involved a common closed lateral wedge osteotomy with an 8 cm lateral incision sufficient to fully accommodate the custom-matched surgical osteotomy template, even though our patient-matched surgical osteotomy guide was relatively larger than those reported in previous studies 6 , 10 , 24 , 25 . The reduction template was specifically designed to assist in precise osteotomy reduction by maintaining the alignment of four Kirschner wires in parallel, temporarily securing them. This design not only ensured accurate reduction without enlarging the original incision but also significantly shortened the reduction time. The patient achieved an excellent outcome, as evidenced by a Hospital for Special Surgery score of 98. The carrying angle improved from − 22.1° (varus) preoperatively to 12.2° (valgus) postoperatively, while the tilting angle improved from 1.3° to 52.3°, closely approximating the contralateral normal side (15.3° valgus and 52.1°). There was no recurrence of the varus deformity, no loss of correction, and no wound-related complications. Bone union was achieved at approximately three months postoperatively. Fixation using a LCP plate was applied on the lateral side, combined with medial Kirschner wire pinning, ensured rotational stability and provided sufficient strength to allow early initiation of active functional rehabilitation. This case demonstrates that accurate 3D correction of pediatric cubitus varus deformity can be achieved through a limited lateral incision. Our method, which uses a custom-matched osteotomy template and reduction template in conjunction with common closed lateral wedge osteotomy, avoids the need for extensive exposure while maintaining surgical precision. The approach resulted in a successful single-stage correction, with satisfactory cosmetic and functional outcomes, and stable fixation. These findings support the potential utility of a limited-incision 3D-guided osteotomy as a viable and efficient treatment option for pediatric patients with cubitus varus deformity. Conclusion Accurate 3D correction of pediatric cubitus varus deformity can be effectively achieved using a custom-matched surgical osteotomy template combined with a reduction template through a limited lateral incision. 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 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 patient 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. Competing interests: All Authors including Mei-Ren Zhang,Jian-Hao Guan,Hai-Yun Chen,Kui-Zhao, Xiao-Zeng and their immediate families declared no benefits in any form have been, or will be received, from any commercial party related directly, or indirectly, to this study. Clinical trial number: Not applicable 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 Contribution Mei-Ren Zhang designed the study and wrote the manuscript. Hai-Yun Chen and Kui-Zhao were involved in the treatment. Xiao Zeng performed literature review.Jian-Hao Guan performed data collection and processing，All authors contributed to writing the manuscript. All authors read and approved the manuscript. Acknowledgement NO Availability of data and materials: The data used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Bauer 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 . 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. 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Efficacy evaluation of three-dimensional printing assisted osteotomy guide plate in accurate osteotomy of adolescent cubitus varus deformity. J Orthop Surg Res. 2019;14(1):353. 10.1186/s13018-019-1403-7 . 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;12:1342980. 10.3389/fped.2024.1342980 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. 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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-6856636","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":485621420,"identity":"587af47d-9e74-4f79-8bf9-c51a59c8f410","order_by":0,"name":"Mei-Ren 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6","display":"","copyAsset":false,"role":"figure","size":1622696,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure16.png","url":"https://assets-eu.researchsquare.com/files/rs-6856636/v1/8c6ec1e42d1456a6efe9023c.png"},{"id":87047877,"identity":"968522c8-6502-463b-9e1d-356d06a8b2b9","added_by":"auto","created_at":"2025-07-18 14:44:02","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1725771,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure17.png","url":"https://assets-eu.researchsquare.com/files/rs-6856636/v1/fd0307e20eec2693b7167f1b.png"},{"id":87466954,"identity":"b37ae5de-0f27-4d30-9e6a-6a7d31732588","added_by":"auto","created_at":"2025-07-24 07:37:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10754878,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6856636/v1/926bd629-06cd-4f1c-95c7-800b40d0d375.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"3D Accurate Osteotomy for Pediatric Cubitus Varus Deformity using a Custom-Matched Surgical Osteotomy Template Combined with a Reduction Template via a Limited Lateral Incision: A Case Report and Literature Review","fulltext":[{"header":"Background","content":"\u003cp\u003eCubitus varus deformity is a common complication following supracondylar humeral fractures in children \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Various methods for three-dimensional (3D) corrective osteotomy have been reported \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. However, these methods differ regarding surgical incisions and internal fixation techniques, and achieving accurate osteotomy through a minimal incision remains technically challenging. Cubitus varus deformity involves three planes: varus in the coronal plane, overextension in the sagittal plane, and internal rotation in the horizontal plane. Here, we introduce a 3D preoperative computer simulation-based approach using custom-printed surgical templates to achieve accurate 3D osteotomy via a limited lateral incision, and we review the relevant literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 12-year-old female presented to our hospital with concerns regarding the cosmetic appearance of her left elbow and limited elbow joint function, eight months after sustaining a supracondylar fracture of the humerus. The patient had been treated initially with an immobilization cast for four weeks, after which the cubitus varus deformity persisted, becoming obvious to her parents. Preoperative photographs and anteroposterior (AP) and lateral X-rays confirmed cubitus varus deformity of the left elbow. The preoperative carrying angles of the normal and affected sides were 15.3° and − 22.1° (varus), respectively, and the tilting angles (TA) were 52.1° and 1.3°, respectively. The elbow's range of motion had returned to a normal range (0°–120°), but showed a 30° limitation compared with the unaffected side. Hyperextension of the elbow and internal rotation of the shoulder were normalized. The patient underwent 3D accurate osteotomy using a custom-made 3D printed surgical template combined with a reduction template via a limited lateral incision. Informed consent was obtained from the patient and her parents prior to publication of this case report.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgery Treatment\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eStep 1: 3D Evaluation of Cubitus Varus Deformity and Planning of the 3D Corrective Osteotomy\u003c/h2\u003e\u003cp\u003eBoth humerus were scanned with the forearms in maximum supination using a CT scanner (Computerized Tomography General Electric LightSpeed-640, GE, Milwaukee, WI) with a low-radiation dose technique. We created 3D bone-surface models of both humerus from digital data and evaluated the deformity three-dimensionally by comparing the affected humerus to a mirror image of the contralateral normal humerus using specialized 3D software (Magics RP; Materialise, Leuven, Belgium) (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The affected humerus was superimposed onto the mirror image of the corresponding part on the contralateral normal side (proximal registration) by translating and rotating the two humeral models until they matched precisely (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). The computer software automatically calculated the 3D deformity based on the transformation data from distal and proximal registration (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). A simulated 3D corrective osteotomy was then performed based on the deformity evaluation data. With the proximal portion of the affected humerus aligned to the mirror image of the contralateral normal side, we placed an osteotomy plane approximately parallel to the distal articular surface and just proximal (0–1 cm) to the olecranon fossa, naming and saving this as the distal osteotomy plane (DOP) (Fig.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Next, the distal humerus from the normal side was precisely superimposed onto the distal part of the affected side by translation and rotation, and the proximal osteotomy plane (POP) was established by shifting the distal osteotomy plane according to the amount of required correction (Fig.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The wedge-shaped segment defined by the DOP and POP was then removed from the affected humerus using the software’s editing function (Fig.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eC-\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). The simulation of 3D correction was completed by moving the distal humerus segment to align with the proximal segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eE). Finally, we verified on the computer monitor that the overall appearance of the extremity had been correctly restored (Fig.\u0026nbsp;\u003cspan refid=\"Fig17\" class=\"InternalRef\"\u003e2\u003c/span\u003eF).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStep 2: Design of Patient-Specific Surgical Guides (Including Surgical Osteotomy and Reduction Templates)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003e1) Design of the Custom-Made Surgical Reduction Template\u003c/h3\u003e\n\u003cp\u003eThe wedge-shaped segment defined by the DOP and POP was removed from the affected humerus. The simulation of the 3D correction was completed by aligning the distal humerus segment to the proximal humerus segment. The reduction guide was shaped to precisely fit the posterolateral surface of the distal humerus after the 3D correction was simulated. Four guide pins (2.0 mm diameter each) were placed parallel to each other, spaced at intervals of 8 mm along the midline of the lateral distal humerus, perpendicular to the humeral axis (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The midpoint between the second and third guide pins was placed directly on the osteotomy surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Using SolidWorks software, the custom-made surgical reduction guide was then designed based on these four guide pins and their exact positions, ensuring it precisely matched the lateral side of the distal humerus (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eC-\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). This guide was designed to facilitate accurate reduction and temporary fixation following osteotomy.\u003c/p\u003e\n\u003ch3\u003e2) Design of the Custom-Made Surgical Osteotomy Template\u003c/h3\u003e\n\u003cp\u003eThe custom-made surgical reduction guide was divided into upper and lower parts at the osteotomy surface using the software, and the distal humerus of the affected side was returned to its original uncorrected position (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eE). Two osteotomy slits were designed along the POP and the DOP, each connected to the upper and lower sections of the surgical reduction guide by a connecting rod, enhancing the stability of the surgical osteotomy guide (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eF). The osteotomy guide was finalized by precisely matching it to the lateral side of the distal humerus using SolidWorks software (Fig.\u0026nbsp;\u003cspan refid=\"Fig23\" class=\"InternalRef\"\u003e3\u003c/span\u003eG). A preoperative simulation of the 3D corrective osteotomy was conducted using the custom-made osteotomy template combined with the reduction template on a 3D-printed model (Fig.\u0026nbsp;\u003cspan refid=\"Fig27\" class=\"InternalRef\"\u003e4\u003c/span\u003eA-\u003cspan refid=\"Fig27\" class=\"InternalRef\"\u003e4\u003c/span\u003eF).\u003c/p\u003e\n\u003ch3\u003eStep 3: Surgical Technique\u003c/h3\u003e\n\u003cp\u003eThe patient underwent osteotomy for cubitus varus deformity (Fig.\u0026nbsp;\u003cspan refid=\"Fig28\" class=\"InternalRef\"\u003e5\u003c/span\u003eA-\u003cspan refid=\"Fig28\" class=\"InternalRef\"\u003e5\u003c/span\u003eC) using the custom-made surgical template combined with the reduction template via a limited lateral incision under general anesthesia, and was positioned supine. A tourniquet was routinely applied and inflated to 200 mmHg. A limited lateral incision extending from 6 cm proximal to 2 cm distal to the elbow crease was made without exposure of the radial nerve. Four 2.0 mm Kirschner wires were inserted through guide pipes on the custom-made surgical osteotomy template after all edges of the guide were confirmed to be in complete contact with the lateral surface of the distal humerus (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). Osteotomy was performed using a saw guided by the cutting slits in the osteotomy template (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eB). The wedge-shaped bone segment was then removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eC). The planned correction was achieved by aligning the four Kirschner wires parallel to each other and securing them temporarily with the reduction template, ensuring complete contact with the bone surface; subsequently, an additional three Kirschner wires were inserted for temporary fixation (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eD-\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eE). Internal fixation was performed using a lateral Locking Compression Plate (LCP) after removing the reduction template; lateral Kirschner wires were then removed while medial Kirschner wires were retained percutaneously. Alignment was confirmed intraoperatively using C-arm fluoroscopy. The passive range of motion immediately after surgery was normal, and the cubitus varus deformity was corrected through an 8 cm lateral incision (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eF-\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eH). The periosteum was sutured, and the skin was closed without drainage. Total operative time was 116 minutes, with intraoperative blood loss of 20 mL.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eAP and lateral X-rays demonstrated accurate correction of the cubitus varus deformity of the left elbow. The carrying angle and tilting angle on the affected side significantly improved from − 22.1° (varus) (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eI) and 1.3° (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eJ) preoperatively, to 12.2° (valgus) (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eK) and 52.3° (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eL), respectively, postoperatively, closely matching the contralateral normal side (Fig.\u0026nbsp;\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eM-\u003cspan refid=\"Fig35\" class=\"InternalRef\"\u003e6\u003c/span\u003eN). Active and passive range-of-motion exercises were permitted on the day following surgery without splint protection.\u003c/p\u003e\u003cp\u003eMedial Kirschner wires were removed two months postoperatively, and complete bone union was achieved three months after surgery. The patient underwent reoperation for asymptomatic hardware removal and had a full range of motion (Fig.\u0026nbsp;\u003cspan refid=\"Fig39\" class=\"InternalRef\"\u003e7\u003c/span\u003eA-\u003cspan refid=\"Fig39\" class=\"InternalRef\"\u003e7\u003c/span\u003eE), good strength, and returned to her previous level of sporting activity. The patient had an excellent outcome according to the Hospital for Special Surgery score, without recurrence of varus deformity, neurovascular injury, or wound complications. Photographs and AP and lateral X-rays confirmed accurate correction of the cubitus varus deformity of the left elbow at the one-year follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig39\" class=\"InternalRef\"\u003e7\u003c/span\u003eG-\u003cspan refid=\"Fig39\" class=\"InternalRef\"\u003e7\u003c/span\u003eI).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCbitus varus deformity is the most common complication of distal humeral fractures in adolescents \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Recent studies have demonstrated that cubitus varus deformity is a 3D deformity involving not only varus angulation but also extension and internal rotation of the distal humeral segment\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Nevertheless, 3D correction has increasingly become the focus of surgical treatment, aiming for complete improvement in both appearance and function\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite the importance of 3D correction, accurately achieving the desired correction of each dimension during surgery remains technically challenging. Surgeons often require repeated adjustments or relying solely on general appearance for guidance, increasing the risk of residual deformity \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eRecent advances in computer simulation technology, patient-matched surgical guides, and 3D printing have addressed these challenges, enabling accurate, simple, and safe 3D correction \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. These technologies allow for precise preoperative planning and accurate intraoperative execution. Several authors have reported excellent outcomes with improved accuracy in osteotomy using 3D technology, and they have recommended this approach as an ideal treatment for cubitus varus deformity \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, compared with conventional procedures, corrective osteotomy using 3D surgical templates may require a larger surgical field or incision position the template. For example, Sri-Utenchai\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. used a standard posterior paratricipital approach with a 20-cm posterior midline incision. Similarly, Zhang et al\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003ereported using a double-incision approach with routine medial and lateral incisions. These approaches ensure accurate correction but at the cost of greater soft tissue exposure.\u003c/p\u003e\u003cp\u003eIn contrast, we achieved accurate 3D corrective osteotomy of cubitus varus deformity using a single limited lateral incision. Our approach involved a common closed lateral wedge osteotomy with an 8 cm lateral incision sufficient to fully accommodate the custom-matched surgical osteotomy template, even though our patient-matched surgical osteotomy guide was relatively larger than those reported in previous studies \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. The reduction template was specifically designed to assist in precise osteotomy reduction by maintaining the alignment of four Kirschner wires in parallel, temporarily securing them. This design not only ensured accurate reduction without enlarging the original incision but also significantly shortened the reduction time.\u003c/p\u003e\u003cp\u003eThe patient achieved an excellent outcome, as evidenced by a Hospital for Special Surgery score of 98. The carrying angle improved from \u0026minus;\u0026thinsp;22.1\u0026deg; (varus) preoperatively to 12.2\u0026deg; (valgus) postoperatively, while the tilting angle improved from 1.3\u0026deg; to 52.3\u0026deg;, closely approximating the contralateral normal side (15.3\u0026deg; valgus and 52.1\u0026deg;). There was no recurrence of the varus deformity, no loss of correction, and no wound-related complications. Bone union was achieved at approximately three months postoperatively. Fixation using a LCP plate was applied on the lateral side, combined with medial Kirschner wire pinning, ensured rotational stability and provided sufficient strength to allow early initiation of active functional rehabilitation.\u003c/p\u003e\u003cp\u003eThis case demonstrates that accurate 3D correction of pediatric cubitus varus deformity can be achieved through a limited lateral incision. Our method, which uses a custom-matched osteotomy template and reduction template in conjunction with common closed lateral wedge osteotomy, avoids the need for extensive exposure while maintaining surgical precision. The approach resulted in a successful single-stage correction, with satisfactory cosmetic and functional outcomes, and stable fixation. These findings support the potential utility of a limited-incision 3D-guided osteotomy as a viable and efficient treatment option for pediatric patients with cubitus varus deformity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccurate 3D correction of pediatric cubitus varus deformity can be effectively achieved using a custom-matched surgical osteotomy template combined with a reduction template through a limited lateral incision.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003cp\u003e\u003cb\u003eDeclarations Ethical Approval\u003c/b\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis 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\u003c/span\u003e the patient and legal guardian \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eprior to the study. This study was approved by Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine.\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWritten informed consent was obtained from the patient\u003c/span\u003e 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\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eAll Authors including Mei-Ren Zhang,Jian-Hao Guan,Hai-Yun Chen,Kui-Zhao, Xiao-Zeng and their immediate families 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\u003ch3\u003eClinical trial number:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\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\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eMei-Ren Zhang designed the study and wrote the manuscript. Hai-Yun Chen and Kui-Zhao were involved in the treatment. Xiao Zeng performed literature review.Jian-Hao Guan performed data collection and processing，All authors contributed to writing the manuscript. All authors read and approved the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eNO\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\n\u003cp\u003eThe data used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBauer AS, Pham B, Lattanza LL. Surgical correction of cubitus varus. 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Epub 2014 Sep 17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\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 Elb Surg. 1995 Jan-Feb;4(1 Pt 1):17\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1058-2746(10)80003-5\u003c/span\u003e\u003cspan address=\"10.1016/s1058-2746(10)80003-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years. J Bone Joint Surg Am. 1978;60(5):657\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\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;14(1):353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13018-019-1403-7\u003c/span\u003e\u003cspan address=\"10.1186/s13018-019-1403-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\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;12:1342980. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fped.2024.1342980\u003c/span\u003e\u003cspan address=\"10.3389/fped.2024.1342980\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pediatric cubitus varus deformity, 3D accurate osteotomy, custom-matched surgical osteotomy template, limited lateral incision","lastPublishedDoi":"10.21203/rs.3.rs-6856636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6856636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCubitus varus deformity is a common complication following a supracondylar fracture of the humerus in children. Due to the limited capacity of the distal humeral epiphysis to spontaneously correct existing varus deformity, this condition typically persists into adulthood without improvement. Accurate correction of this deformity is essential to prevent late sequelae and significantly enhance cosmetic appearance. However, achieving precise correction through a limited incision is technically challenging.\u003c/p\u003e\u003cp\u003eCase Presentation:\u003c/p\u003e\u003cp\u003eWe present the case of a 12-year-old female who sustained a supracondylar fracture of the left humerus after a fall when she was 11 years old. The patient was initially treated with an immobilization cast at another hospital. Four weeks after cast removal, a cubitus varus deformity was noted, and it persisted for 8 months following the initial injury. The patient was then referred to our hospital seeking complete functional and cosmetic improvement. The patient underwent a three-dimensional (3D) accurate osteotomy using a custom-made surgical template combined with a reduction template via a limited lateral incision. The operation time was 116 minutes, with an intraoperative blood loss of 20 mL. The carrying angle and tilting angle on the affected side improved significantly from \u0026minus;\u0026thinsp;22.1\u0026deg; (varus) and 1.3\u0026deg; preoperatively to 12.2\u0026deg; (valgus) and 52.3\u0026deg;, respectively, postoperatively. Bone union was achieved at 3 months after surgery. At the one-year follow-up, the patient had an excellent outcome with a Hospital for Special Surgery score of 98, and without recurrence of the varus deformity, neurovascular injury, or wound complications.\u003c/p\u003e\u003cp\u003eConclusion:\u003c/p\u003e\u003cp\u003eAccurate 3D correction of pediatric cubitus varus deformity can be successfully achieved using a custom-matched surgical osteotomy template combined with a reduction template via a limited lateral incision.\u003c/p\u003e","manuscriptTitle":"3D Accurate Osteotomy for Pediatric Cubitus Varus Deformity using a Custom-Matched Surgical Osteotomy Template Combined with a Reduction Template via a Limited Lateral Incision: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 14:43:55","doi":"10.21203/rs.3.rs-6856636/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a51046c0-fd79-4520-88c4-deaed4baab69","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-18T14:51:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 14:43:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6856636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6856636","identity":"rs-6856636","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}