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Original Clinical Article
Posteromedial bowing of the tibia: a benign condition
or a case for limb reconstruction?
J. Wright1,2
R. A. Hill1
D. M. Eastwood1,2
A. Hashemi-Nejad2
P. Calder2
S. Tennant2
Abstract
Purpose To review the initial deformity and subsequent re-
modelling in posteromedial bowing of the tibia and the out-
come of limb reconstruction in this condition.
Patients and Methods In all, 38 patients with posteromedi-
al bowing of the tibia presenting between 2000 and 2016
were identified. Mean follow-up from presentation was 78
months. A total of 17 patients underwent lengthening and
deformity correction surgery, whilst three further patients are
awaiting lengthening and deformity correction procedures.
Results The greatest correction of deformity occurred in the
first year of life, but after the age of four years, remodelling
was limited. The absolute leg-length discrepancy (LLD) in-
creased throughout growth with a mean 14.3% discrepan-
cy in tibial length. In the lengthening group, mean length
gained per episode was 45 mm (35 to 60). Mean duration
in frame was 192 days, with a mean healing index of 42.4
days/cm. Significantly higher rates of recurrence in LLD were
seen in those undergoing lengthening under the age of ten
years (p = 0.046). Four contralateral epiphysiodeses were also
performed.
Conclusion Posteromedial bowing of the tibia improves spon-
taneously during the first years of life, but in 20/38 (53%)
patients, limb reconstruction was indicated for significant
residual deformity and/or worsening LLD. For larger discrep-
ancies and persistent deformity, limb reconstruction with a
hexapod external fixator should be considered as part of the
treatment options.
Level of evidence Level IV (Case series)
1 Department of Orthopaedics, Great Ormond Street Hospital for
Children, London, UK
2 Catterall Unit, Royal National Orthopaedic Hospital, Stanmore, UK
Correspondence should be sent to J. Wright, Catterall Unit,
Royal National Orthopaedic Hospital, Stanmore, UK.
E-mail: jwrightortho@gmail.com
Cite this article: Wright J, Hill RA, Eastwood DM, Hashemi-
Nejad A, Calder P, Tennant S. Posteromedial bowing of the
tibia: a benign condition or a case for limb reconstruction?
JChild Orthop 2018;12. DOI 10.1302/1863-2548.12.170211
Keywords: Posteromedial bowing; tibia; limb reconstruction;
tibial recurvatum
Introduction
Congenital posteromedial bowing of the tibia is a rare
condition first described by Heyman and Herndon in
19491 which has also been termed kyphoscoliosis of the
tibia2 or tibial recurvatum.3 The literature on this condition
is limited; the largest series describing the natural history
to date is by Pappas (1984),4 which describes a group of
33 patients.
Traditionally, posteromedial bowing is considered a
‘benign condition’5 in view of its potential to remodel,2,4,6
particularly in comparison with the less favourable associ-
ations of anterolateral bowing with tibial pseudarthrosis
or anteromedial bowing with fibular hemimelia.
It is accepted that remodelling is not usually complete,
and that leg-length discrepancy (LLD) increases with age
and may be up to 7 cm at maturity.4,5,7 Some authors have
suggested that surgery should play a greater role in the
management of posteromedial bowing than simple epiph-
ysiodesis, either through the use of osteotomy for defor-
mity correction7-9 and/or limb lengthening techniques.7,10
The aim of this study was firstly to review the initial
remodelling of deformity in the condition in cases present-
ing to two tertiary centres prior to any intervention, and
secondly to assess the outcome of limb reconstruction and
other surgeries for limb-length equalization and deformity
correction, in order to better define management protocols.
Patients and methods
Cases were identified from the patient databases of two
tertiary referral hospitals. Inclusion criteria were any cases
of posteromedial bow of the tibia seen during the study
period between 2000 and 2016. Local clinical governance
and audit registration was obtained prior to data collec-
tion (Royal National Orthopaedic Hospital, Stanmore, UK,
registration number SE17.031; Great Ormond Street Hos-
pital, London, UK, registration number 2232). Exclusion
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
criteria were a lack of radiographic data (three patients),
or if the patient was only seen for initial assessment with
ongoing follow-up being within a local hospital (one
patient). A total of 42 patients were identified with four
exclusions, providing a total of 38 patients for analysis.
Demographic data is shown in Table 1. In all, 22 patients
were seen from under six months of age; the remaining 16
patients were referred later in childhood.
The analysis consisted of two parts: the initial defor-
mity/remodelling and the limb reconstruction group.
Initial deformity and remodelling
To assess the initial deformity and remodelling in postero-
medial bowing, data was collected from clinical notes and
radiographs. Measurements included: severity of defor-
mity at presentation, type of foot deformity and change
of angulation on standardized sequential radiographs in
the anteroposterior and lateral planes. Shortening was
assessed clinically and radiographically with long-leg
standing radiographs to record the relative shortening of
the affected tibia in relation to the normal side. If a patient
underwent intervention for deformity or LLD, the data fol-
lowing this intervention was not used in the assessment
of natural history.
Limb reconstruction group
Patients who went on to require lengthening and/or
deformity correction formed the second part of the study.
A total of 17 patients underwent lengthening with 19
separate lengthening episodes. Three further patients are
planned for lengthening/deformity correction as their pri-
mary procedure at a future date according to predicted
LLD (between 45 mm and 80 mm). Medical notes and
radiographs determined length gained, time in frame,
bone healing index and any complications. Any recurrence
of LLD was noted in the follow-up, along with require-
ment for further procedures. Indications for epiphysiode-
sis alone were a predicted LLD > 2 cm with no significant
angular deformity. Indications for limb reconstruction
included a predicted LLD of > 5 cm or symptomatic resid-
ual angular deformity after the age of four years with an
associated LLD. No patients were seen with angular defor-
mity alone, without a LLD.
Statistical analysis
This was performed using SPSS 23 (IBM, New York,
NewYork) for Mac. Unless otherwise stated, categorical
variables are expressed as frequency (percentage) and
continuous variables are expressed as mean (range)
with p < 0.05 considered as statistically significant. Non-
parametric group comparisons of continuous data were
made with the Mann-Whitney U test. Correlation coef-
ficients were calculated using Spearman’s test. Fisher’s
exact test was used for categorical data.
Results
Initial deformity and remodelling
A prenatal diagnosis of a lower limb abnormality was
made in 16/24 (66%) of patients from the 20-week anom-
aly scans. Only one patient received a correct diagnosis of
posteromedial bowing on the anomaly scan, the remain-
ing patients being reported as: tibia/fibula shortening
(nine patients), congenital talipes equinovarus (three
patients), fibular hemimelia (two patients) or ‘lower limb
abnormality’ (one patient). For the 22 patients present-
ing within six months of birth, a calcaneovalgus foot was
described in 17 patients, and a normal foot/ankle appear-
ance in five patients.
Angular deformity
On initial presentation, in the subgroup of 22 patients
who were seen at less than six months of age, the mean
medial bow was measured as 43° (5° to 70°) and the
mean posterior bow 35° (7° to 71°). For all patients,
thedegree of bow was seen to improve over time, with
the greatest rates of correction seen within the first year of
life. Figures1 and 2 demonstrate the radiographic appear-
ances of the deformity and subsequent improvement
over time. Figures 3 and 4 graphically demonstrate the
improvement in tibial bowing over time divided into the
posterior and medial components of the deformity. There
is a greater time period over which the medial bow mea-
surements are available, reflecting the greater number
of long-leg radiographs taken in comparison with lateral
views in the older patients.
Table 2 shows the rate of correction of the posterior
and medial components of the bow over differing time
periods. There is a non-significant trend for a greater rate
of correction of the posterior bow in comparison with the
medial bow (p = 0.158). Although there is not a clear cut-
off for the point at which remodelling ceases, most of the
improvement is seen in the first four years of life.
LLD
The femur did not contribute to LLD. Figure 5 demon-
strates the progressive increase in clinical LLD with time
(Spearman’s R = 0.848, p < 0.001). The mean percentage
shortening of the tibia was not seen to change over time
Table 1 Demographic details for all patients included in study (n = 38)
Demographic Result
Mean (range) age at presentation in months 33 (0 to 221)
Male:Female 16:22
Left:Right 22:16 (all cases were unilateral)
Mean (range) follow-up in months 78 (9 to 197)
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
Fig. 1 (a) Long-leg anteroposterior (AP) radiograph demonstrating posteromedial bowing of the right tibia at presentation aged three
months; (b) lateral radiograph demonstrating posteromedial bowing of the right tibia at presentation aged three months.
Fig. 2 (a) Long-leg anteroposterior radiograph demonstrating some remodelling of right tibia, with increase to 4 cm leg-length
discrepancy aged six years; (b) lateral radiograph demonstrating some remodelling of right tibia, with increase to 4 cm leg-length
discrepancy aged six years.
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
Fig. 3 Graph demonstrating improvement in posterior bowing with increasing age. Each line represents the change in one patient.
Fig. 4 Graph demonstrating improvement in medial bowing with increasing age. Each line represents the change in one patient.
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
in each patient, with a mean across all patients of 14.3%
(4% to 25%). There was a significant association between
severity of bow and percentage LLD for posterior bowing
(Spearman’s R = 0.851, p = 0.015), but not as strong for
medial bowing (Spearman’s R = 0.619, p = 0.075).
Table 3 summarizes the interventions required within
the patient group studied. Four patients underwent prox-
imal tibial epiphysiodesis and four patients are await-
ing epiphysiodesis, according to predicted LLD, as their
primary treatment. One patient with a significant LLD
declined intervention as her underlying psychological/
behavioural issues precluded limb reconstruction and
insufficient growth was remaining for an epiphysiodesis.
Of the nine patients managed conservatively, eight are
under continuing observation, as they are under the age
of four years. The final patient has remodelled the angular
deformity but has a predicted LLD of > 5 cm, although
the family have not yet made a decision about limb length
equalization.
Limb reconstruction group
In all, 17 patients underwent 19 episodes of limb recon-
struction during the study period. All patients except one
(18/19 episodes) underwent limb reconstruction using
the Taylor Spatial Frame (TSF; Smith & Nephew, Memphis,
Tennessee), the remaining one being performed with a
monolateral fixator (Stryker, Newbury, United Kingdom).
Figures 6 and 7 demonstrate an example of the radio-
graphic appearances of the tibia both during and follow-
ing the lengthening procedure with the TSF.
Bifocal lengthening (‘Stacked TSF’) was used in three
cases, in which deformity correction was achieved at the
distal osteotomy with further lengthening at the proxi-
mal osteotomy to limit time in the frame, due to the bet-
ter healing potential of a metaphyseal osteotomy.11 This
technique was considered where the angular deformity
necessitated a mid-diaphyseal osteotomy with > 3 cm
lengthening required. As this is a retrospective multi-sur-
geon series, the final decision for the frame construct was
down to surgeon choice.
The aim of limb reconstruction was to correct defor-
mity and equalize leg lengths: it was understood that, in
the presence of pathology that affected growth, a discrep-
ancy would return over time.
Table 2 Rate of improvement in bowing over rst ve years of life. All
gures in degrees per month
Year 1 2 3 4 5 >5
Medial bowing 1.78 0.553 0.306 0.21 0. 11 0.085
Posterior bow 2.43 0.755 0.315 0.17 5 0.052 0.0375
Fig. 5 Scatter graph demonstrating increasing leg-length discrepancy as age of patient increases.
Table 3 Summary of the primary treatments undergone
Treatment n = 38
Lengthening/deformity correction
Awaiting due to predicted LLD
Declined lengthening
17 patients (19 episodes)
3 patients (predicted LLD 45 mm
to 80 mm)
1 patient (LLD 70 mm)
Proximal tibial epiphysiodesis
Awaiting due to predicted LLD
4 patients performed
4 patients awaited
Continued observation/nonoperative 8 patients aged < 4 yrs
1 patient undecided (predicted
LLD 5.4 cm)
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
Fig. 6 Anteroposterior radiograph of the right tibia during frame correction of deformity and lengthening.
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
The demographics and details of deformity correction
are summarized in Table 4. Torsional deformities could not
be assessed from radiographs, but from the clinical notes
where not thought to be a significant element of the defor-
mity requiring correction. Target length was achieved in
18/19 lengthening episodes, with one stopped early due
to development of an equinus contracture, which subse-
quently improved with physiotherapy alone.
Complications and recurrence
Complications from lengthening and recurrences are
summarized in Table 5. It was noted that all of the patients
Fig. 7 (a) Anteroposterior radiograph demonstrating appearance of right tibia following correction; (b) lateral radiograph
demonstrating appearance of right tibia following correction.
Table 4 Demographics and details of deformity correction in limb recon-
struction group (n =17)
Criteria Result
Age at time of surgery (range) 10 yrs (4 to 18)
Method of deformity correction Taylor Spatial Frame - 18 episodes
Monolateral fixator - 1 episode
Inclusion of heel in fixator construct 10/19 episodes
Mean deformity at time of surgery
(range)
Medial bow 13.3° (0° to 35°)
Posterior bow 9.9° (0° to 32°)
Mean deformity at latest follow-up
(range; significant improvement)
Medial bow 2.8° (-3° to 12°; p = 0.001)
Posterior bow 2.3° (0° to 9°; p = 0.003)
Mean length gained (range) 45 mm (35 to 60)
Mean duration in frame (range) 192 days (129 to 287)
Mean healing index (range) 42.4 days/cm (31.1 to 60.9)
Mean follow-up from removal of
frame (range)
32 months (2 to 80)
Skeletal maturity at latest follow-up 10/17 patients
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
requiring surgical intervention for joint contracture did
not have the heel included in the frame construct for the
lengthening process. No nerve injuries, episodes of non-
union or fractures following frame removal were seen.
At the time of latest follow-up the mean LLD in the
lengthening group was 10mm (0 mm to 30 mm). Signif-
icant recurrent LLD (> 10 mm) was seen in six patients.
Out of these six patients, two underwent a subsequent
epiphysiodesis, two underwent a second period of length-
ening and two patients declined any further treatment.
The age of intervention was shown to be important with
4/6 patients lengthened under the age of ten years devel-
oping significant further LLD, while only 2/13 of those
lengthened over the age of ten years showed significant
recurrence at latest follow-up (Fishers exact test, p =
0.046). Age at latest follow-up was a mean of 13.8 years (8
to 21) with ten patients having reached skeletal maturity.
Discussion
This study represents the largest series of patients present-
ing with posteromedial bowing of the tibia that has been
described to date. The series has replicated the perceived
understanding that the bowing deformity improves with
time, if not completely. The rate of correction was seen
to be greatest during the first year, with decline after
this. There is no clear point at which remodelling ceases,
although our data does support the suggestion that after
four years, no further clinically important remodelling
occurs.4,7-9 There was a non-significant trend for a faster
rate of correction of the posterior component of the bow
than the medial. This is consistent with the theory that
deformities correct more rapidly in the plane of move-
ment of the adjacent joints than those perpendicular to
that plane.9,12
The initial degree of bowing showed a strong correla-
tion to the proportional LLD. This was also commented
upon by Shah et al,9 who conversely observed a greater
correlation with the medial bow than the posterior, in a
small subgroup of their patients where the data was avail-
able. As the posteromedial bow represents an oblique
plane deformity,13 it would seem sensible that it is the
total magnitude of the bow that predicts the discrepancy,
rather than one plane in particular.
The LLD was seen to increase relentlessly throughout
growth (as demonstrated in Figure 5), although the per-
centage growth inhibition remained constant in com-
parison with the normal side. This is consistent with a
congenital (Type 1) picture of LLD as described by Sha-
piro,14 which should allow for an accurate prediction of
final discrepancy from population data.15 In the infant, the
accuracy of measurement of percentage shortening may
not be reliable to use for prediction, but by the age of four
years both the quality of radiographs and the absolute size
of the patient should allow for sufficient accuracy of mea-
surement to provide a more useful prediction of final LLD
to develop a surgical plan. The relative tibial shortening
seen in this series was comparable with the previous pub-
lished data of a mean of 12% to 15%,4,9 although there is a
range of severity. Although the aetiology of posteromedial
bowing is not fully understood,16,17 a true congenital cause
rather than intrauterine fracture or crowding would better
explain the ongoing growth disturbance. Our data would
support this due to the presence of abnormality from the
time of the 20-week anomaly scan. Impaired function of
the distal tibial physis has been suggested as the source
for the shortening, which persists throughout growth.4,10
In this series of 19 episodes of lengthening in 17 patients,
the required length was achieved in 18/19 procedures.
The healing index of 42 days/cm was comparable with
the literature for lengthening of congenital tibial defor-
mity,10,18,19 with no significant problems seen in regener-
ate formation or bone healing. The previously published
use of limb-lengthening techniques in posteromedial
bowing of the tibia is limited, with Shah9 reporting two
patients, Johari7 six patients and Kaufmann et al10 describ-
ing a series of 11 patients undergoing limb lengthening
with the Ilizarov method. Newer techniques may prove
to further shorten the time in frame such as lengthening
over flexible nails20,21 or lengthening and then plating,22,23
although these techniques have not been reported in this
cohort of patients.
The main complications seen, beyond pin site infec-
tions, were related to soft-tissue and joint contractures.
Including the heel in the frame construct may reduce
the risk of equinus contracture, although other methods
have also been described to overcome such contracture
during tibial lengthening, including pre-emptive soft-tis-
sue release24 and temporary extra articular arthrodesis.25
As a retrospective study between two centres, there was
no set indication for including the foot in this series. How-
ever, the current practice among the authors is now to
include the foot in the construct if lengthening of greater
than 2 cm is required. One patient (the earliest undergo-
ing lengthening) was treated with a monolateral fixator,
who went on to develop a deformity of the regenerate.
Table 5 Summary of complications and recurrences of leg-length dis-
crepancy in limb reconstruction group (n = 17)
Complication n Treatment
Superficial pin site infection 5 Oral antibiotics
Deformity of regenerate 1 Corrected with wedged long-leg plaster
Premature consolidation of
proximal osteotomy in bifocal
lengthening
1 Target length obtained from distal
osteotomy
Joint contractures 9 6 responded to physiotherapy
3 required surgery
1 posteromedial release
1 tendoachilles lengthening
1 manipulation under anaesthesia at
frame removal
POSTEROMEDIAL BOWING OF THE TIBIA
J Child Orthop 2018;12.
This complication was not seen in the remaining patients
treated with the TSF, which reflects the greater control
achieved with a hexapod fixator,10,26 rather than the sur-
geon’s learning curve.
We have demonstrated that the risks of recurrence of
LLD are significantly higher if lengthening is performed
before the age of ten years. With an ongoing growth
inhibition, the risk of recurrence is important to consider
both in the decision for timing of surgery and in coun-
selling of parents. If the child still has significant bowing
deformity beyond the age of four years, then expected
further remodelling will be limited. At this time, correc-
tion of deformity with lengthening could be considered,
with the understanding that if the length is not corrected
according to the predicted discrepancy at maturity, (i.e.
overlengthening the tibia at initial treatment) the patient
will likely require further treatment. This may include
either a subsequent period of lengthening or a contra-
lateral epiphysiodesis to correct the ongoing growth dis-
turbance. Calculation of the magnitude of the predicted
discrepancy at maturity should help guide which of these
options would be preferable. If, however, the bowing
deformity has remodelled to an extent that it does not
cause functional or significant cosmetic impairment, then
our preference is to wait until closer to skeletal maturity
to perform lengthening. This serves to not only limit the
number of procedures required but also, the more mature
child may manage the lengthening process better. The
age at which lengthening is performed may also affect the
residual growth from the physis, although this effect has
not been fully quantified.27
As this study was carried out between two tertiary cen-
tres, along with the benefit of providing a large patient
group, it does bring limitations. The older patients
referred on to a tertiary centre are likely to represent the
worse end of the spectrum of the condition and as such
are more likely to require intervention. This may have led
to an overestimation of the number of patients requiring
limb lengthening (greater than 50% in this series). As a
large proportion of the patients underwent interven-
tion, this limits the assessment of the true natural history,
with assessment focussed on the period before a surgical
intervention. The retrospective design relies on the radio-
graphic data that is available, with radiographs taken at
variable time points according to when patients attended
clinic. Despite this limitation, due to the usual care involv-
ing regular monitoring of the deformity, a reasonable
number of data points have been obtained for this patient
group.
The same device was used for the majority of the
lengthening procedures, however, these were performed
by five different surgeons in two independent centres,
without standardization of treatment, so specific learning
points relating to the technique should be taken with care.
As not all patients were skeletally mature at the time of lat-
est follow-up, the study may underestimate late compli-
cations and recurrence. Indeed, smaller increases in LLD
(< 10 mm) were seen at follow-up in most of the length-
ening patients with growth remaining, which would be
consistent with an ongoing congenital growth distur-
bance. However, logic would suggest that this is unlikely
to change the finding that the patient undergoing length-
ening at a younger age is at higher risk of recurrence.
In conclusion, congenital posteromedial bowing of the
tibia does improve significantly during the first years of
life, although may leave residual deformities and wors-
ening LLD. For larger discrepancies and those associated
with angular deformity, limb lengthening with a hexapod
external fixator should be considered as part of the treat-
ment options, although careful consideration is required
in both selection and timing of limb equalization proce-
dures.
Received 14 December 2017; accepted after revision 15 February 2018.
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FUNDING STATEMENT
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party related directly or indirectly to the subject of this article.
OA LICENCE TEXT
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ETHICAL STATEMENT
Ethical approval: All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the institutional and research
committee and with the 1964 Helsinki declaration and its later amendments or com-
parable ethical standards.
Informed Consent: Informed consent was not required for this work.
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