Original article 479
Congenital postero-medial bowing of the tibia and fibula:
is early surgery worthwhile?
Ashok N. Joharia, Arjun A. Dhawalea, Abhijit Salaskara and Alaric J. Aroojisb
We report the results of surgical treatment of congenital
postero-medial bowing of the tibia and fibula. Twenty
patients with congenital postero-medial bowing were seen
with nine patients treated surgically (corrective osteotomy
c 2010 Wolters Kluwer Health |
or lengthening and deformity correction with Ilizarov
fixator) and 11 patients managed conservatively. The
angles of medial and posterior angulation and limb
length discrepancy were recorded serially and compared.
Surgical complications were recorded. The mean follow-up
was 9.5 and 6.1 years after surgery. Although there was
a reduction in angulation and correction of limb length
discrepancy, we encountered complications in the
surgically treated patients. There was no statistically
significant difference between the surgically treated and
conservatively managed groups with respect to mean
angulation, though there was a significant difference
Introduction
Congenital postero-medial bowing of the tibia and fibula
has been described as a benign, self-resolving condition,
where bowing of the tibia and fibula is seen at birth with
a calcaneovalgus deformity of the foot [1–5]. The medial
and posterior bowing does not resolve completely in all
cases and the residual bowing may require a corrective
osteotomy [4–7]. A significant limb length discrepancy
develops in many cases, which will require surgical treat-
ment in the form of an epiphysiodesis or limb lengthen-
ing [2,3,4,7].
Earlier investigators have described corrective osteotomy
for the bowing and epiphysiodesis and limb lengthening for
the limb length discrepancy. However, there are no clearly
defined indications regarding the selection of patients,
timing of surgery, surgical details, follow-up and results
of the treatment in the literature.
The aim of this study was to critically analyze our experi-
ence with the surgical treatment of congenital postero-
medial bowing of the tibia and fibula, and to compare the
results in the surgically treated group with the conserva-
tively managed group of patients.
Patients and methods
We treated 31 children with congenital postero-medial
bowing of the tibia and fibula from 1991 to 2009.
Complete serial clinical and radiological records till final
review were available in 20 patients. Nine patients
underwent surgery for correction of the bowing, intorsion
and limb length discrepancy, and 11 patients were
managed conservatively.
1060-152X
c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
in the mean limb length discrepancy. In conclusion, we
advocate a one-stage lengthening and correction of the
residual deformity closer to skeletal maturity. J Pediatr
Orthop B 19:479–486
Lippincott Williams & Wilkins.
Journal of Pediatric Orthopaedics B 2010, 19:479–486
Keywords: complications, congenital postero-medial bowing tibia,
surgical treatment
a
Children’s Orthopaedic Centre and bKDA Hospital, Mumbai,
Maharashtra, India
Correspondence to Ashok N. Johari, MS, MCh, FRCS, FAMS, Children’s
Orthopaedic Centre, Bobby Apartments, Lady Jamshedji Road, Mahim,
Mumbai, Maharashtra 400 016, India
Tel: + 91 22 2445 9595; fax: + 91 22 2436 3030;
e-mail: drashokjohari@hotmail.com
Patients were serially examined and at each evaluation,
the severity of the deformity and position of the foot were
noted. The limb length discrepancy was recorded and the
thigh foot angle was measured for clinical assessment of
the tibial intorsion. Antero-posterior (AP) and lateral roent-
genograms were studied at six monthly intervals initially
and then on an annual basis. The angles of the medial
bowing of the tibia and fibula were measured on the AP
radiograph and the posterior angulation of the tibia and
fibula were measured on the lateral radiograph. The anato-
mical medial proximal tibial angle and anatomical lateral
distal tibial angle were measured on the AP radiograph.
Measurements were taken on true AP and lateral
radiographs. Values from radiographs that were not well
centered were discarded. The limb length discrepancy
was measured on the annual scanogram when available.
Surgically treated group
Of the nine cases, there were five males and four females.
The right side was involved in four cases and the left side
in five cases. The mean follow-up was 9.5 years since
presentation and 6.1 years since surgery.
The patients were subdivided into two groups:
Group O (three patients)
The osteotomy group, where tibial osteotomy with K wire
fixation along with fibular osteotomy was done. Our
indications for surgery were for correction of the bowing
deformity in one patient (O1) and correction of the tibial
intorsion in two patients (O2, O3). No lengthening was
done in these cases. The mean age at surgery was 3.7
years (Table 1).
DOI: 10.1097/BPB.0b013e32833ccac2
 480 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 6

Table 1 Osteotomy group

Age at Age at Age at
presentation operation follow-up Presentation Preoperative Preoperative Last follow-up

Follow-up since
Days, Years, Medial Posterior Medial Posterior Medial Posterior Medial Posterior LLD, surgery (years,
Patient months Years + months months angle angle angle angle angle angle angle angle cm months)

O1 1+0 2+9 6+6 45 45 35 40 10 24 14 9 5.5 3+9

O2a 4+0 8+2 14 + 0 32 38 9 10 5 5 8 0 2.5 5 + 10
O3a 0+4 1+0 8+0 50 40 38 30 0 5 8 8 4.0 7+0
Mean 9.5 42.3 41 27.3 26.6 5 11.3 10 5.6 4.0 5.5
Standard 9.2 3.6 15.9 15.2 5 10.9 3.5 4.9 1.5
deviation

All angles in degrees.

LLD, limb length discrepancy.
a
Osteotomy done for tibial intorsion.

Table 2 Lengthening group

Age at Age at Age at
presentation operation follow-up Presentation Preoperative Last follow-up

Days,
months, Years, Medial Posterior Medial Posterior LLD, Medial Posterior LLD, Follow-up since surgery
Patient years Years + months months angle angle angle angle cm angle angle cm (years, months)

L1 2+0+0 4+0 12 + 0 63 59 38 21 4 9 3 0 8+0

L2 10 + 0 + 0 3+9 12 + 0 46 62 20 33 3.7 6 10 2.5 8+3
L3 2+0+0 2+9 11 + 0 42 58 12 30 3.2 10 8 2 8+3
L4 0+5+0 3+3 10 + 0 40 50 20 40 3.6 – 3, 0 – 1a 6+9
proximal
7
L5 10 + 0 + 0 3+5 10 + 0 50 60 34 30 3.7 7 2 1 6+7
L6 0 + 0 + 12 12 + 3 14 + 6 12 12 12 12 5.4 7 5 0 2+6
Mean 11.5 42.1 50.1 22.6 27.6 3.93 6.0 4.6 0.8 6.7
Standard 16.8 19.1 11 9.8 0.76 4.6 3.7 1.3
deviation

All angles in degrees.

LLD, limb length discrepancy.
a
Indicates lengthening.

The procedure involved osteotomy of the tibia and fibula
at the apex of the deformity and K wire fixation along with
elevation of the periosteal sleeve to stimulate growth.
The time taken to achieve union, clinical appearance after
surgery, radiological measurements of medial and poster-
ior angulation of the tibia and fibula and complications
of treatment were recorded. The mean follow-up was
9.5 years since presentation and 5.5 years since surgery.
Group L (six patients)
The lengthening group comprised patients who had an
osteotomy of the tibia and fibula with application of
an Ilizarov ring fixator. Our indications for surgery were
a medial and/or posterior bowing of 301 or more with a
limb length discrepancy of more than 3 cm at the age of
3 years. Except for one patient who was operated at the
age of 12 years, the mean age at surgery was 3.3 years.
The Ilizarov ring fixator was used in all cases. A single-
level osteotomy of the tibia and fibula was performed
in three cases (L1, L3, and L6) and a two-level osteotomy
of the tibia was performed in three cases (L2, L4, and
L5) with deformity correction at the distal osteotomy and
lengthening at the proximal osteotomy. Acute correction
of the deformity was done in five cases, whereas in
patient L6 gradual correction with lengthening was done
(Table 2).
The details of the surgical technique, time duration in
the frame, amount of lengthening achieved, time for con-
solidation of regenerate, radiological measurements of
medial and posterior bowing and complications of treat-
ment were recorded (Table 3). The mean follow-up since
presentation was 9.5 years and since surgery was 6.7 years
with the mean age at the last follow-up being 10 years.
Conservatively managed group
This group comprised 11 patients with nine males and
two females. Conservative treatment included correction
of the calcaneovalgus foot deformity with plaster casts
and splints in the initial period and annual follow-up with
a shoe raise for limb length discrepancy. The right side
was involved in eight and the left side in three cases. The
mean follow-up since presentation was 9.4 years. These
patients did not undergo surgical intervention as they had

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 Congenital postero-medial bowing of the tibia Johari et al. 481

Table 3 Lengthening group – operation details

Time in frame Lengthening Medial angle, Posterior angle, Length gained
Patient (months) index postoperative postoperative (cm) Complications/final status

L1 9 0.9 12 11 7 Fracture through consolidate

Valgus angulation (91)
L2 5 1 0 0 5.5 Residual posterior angulation (101)
L3 9 1 3 20 5 Atrophic regenerate
Fibula nonunion
Recurvatum deformity (81)
Valgus angulation (101)
L4 9 0.6 –5 10 5 Fracture through consolidate
Proximal valgus (71) and distal varus (31)
angulation
L5 7 0.6 10 8 4.5 Valgus angulation (71)
L6 7 0.6 4 4 7.5 Valgus angulation (71)
Mean 7.6 0.8 4 8.8 5.75
Standard 1.6 0.2 6.29 6.8 1.2
deviation

All angles in degrees.

a medial and posterior angulation of less than 301 and
a limb length discrepancy of less than 3 cm at 3 years.
Results
Osteotomy group (Group O)
There was a significant decrease in the mean medial and
posterior angles after surgery and at the last follow-up
(Table 1). There was a clinical improvement in the tibial
intorsion in cases O2 and O3 as assessed by the thigh foot
angle; however this could not be radiologically documented.
Complications occurred in patient (O1), who developed
an infection at the tibial osteotomy site necessitating an
early removal of the K wires. The patient subsequently had
a nonunion of the tibial osteotomy, and phemister bone
grafting was done. The osteotomy united in 6 months.
At follow-up of 3 years and 9 months since surgery, the
patient has a valgus deformity at the ankle with growth
arrest as reflected by an abnormal lateral distal tibial angle
of 751 and a tibial extorsion deformity of 151 as assessed
clinically by the thigh foot angle measurement.
Patient O2 had a residual tibial valgus angulation of 81
at follow-up of 5 years and 10 months since surgery.
Lengthening group (Group L) (Figs 1–6)
Angulation
There was a significant decrease in the mean medial and
posterior angles at the last follow-up (Table 2).
Limb length discrepancy
Preoperatively, the mean limb length discrepancy was
3.93 cm and 0.8 cm at the last follow-up (Table 3).
Complications occurred in all six cases (Table 3).
Fracture: this occurred in two patients and was treated
with cast immobilization. The fractures occurred after
the removal of the fixator.
Atrophic regenerate: this occurred in one patient and
required maintenance in the fixator for 6 months, before
the regeneration consolidated.
Fibula non-union: this occurred in one patient at the site of
osteotomy. The fibula had not united at the last follow-
up, but the patient was asymptomatic.
Valgus angulation: residual valgus angulation occurred in
five cases. The mean residual valgus angulation was 7.81
at the last follow-up. In one patient, there was valgus
angulation (initially 151) at the proximal osteotomy while
the distal osteotomy was in varus (51). This was reflected
by an abnormal medial proximal tibial angle of 1051
proximally. This deformity necessitated an osteoclasis and
a repeat osteotomy with K wire fixation 6 months after
the fixator removal. The remaining cases had valgus
angulation at the distal osteotomy.
Posterior angulation of 8 and 101 was seen in two patients.
Additional surgical procedures: patient L1 underwent a
posterior release and tendoachilles lengthening to correct
equinus. Patient L2 required tendoachilles lengthening
with plantar fasciotomy and fractional release of the flexor
digitorum longus for the correction of an equinocavus foot
deformity.
Conservatively managed group
At 3 years, the mean medial angulation was 15.71, the mean
posterior angulation was 141 and the mean limb length
discrepancy was 2.3 cm. At the last follow-up, there was a
significant decrease in the mean angulation, although the
limb length discrepancy increased to 3.5 cm (Table 4). We
will need to follow this group to skeletal maturity.
Comparison of the surgical and conservative groups
We compared the mean angulation and limb length discrep-
ancy between the two groups. The independent samples
t-test was applied for the comparisons. We did not find
a statistically significant difference (P < 0.05) in the mean

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 482 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 6
Fig. 1
Congenital postero-medial bowing of the tibia and fibula (preoperative).
Fig. 2
Lengthening and deformity correction with Ilizarov fixator.
medial and posterior angulation between the two groups at
the last follow-up (Figs 7 and 8) There was a significant dif-
ference in the limb length discrepancy (P < 0.05) (Fig. 9).
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Fig. 3
Residual posterior angulation at follow-up.
Discussion
Congenital postero-medial bowing of the tibia is con-
sidered as a benign condition by most investigators, in
contrast to anterolateral bowing of the tibia, as there is
no risk of pathological fracture or pseudarthrosis [2–5].
The bowing, which does not completely resolve in all cases,
and the temporally increasing limb length discrepancy
often require treatment. There are no clearly defined
guidelines for the surgical treatment of congenital postero-
medial bowing of the tibia. Pappas [4] advocated a
corrective osteotomy after the age of 3 years for a severe
medial bowing. In his series, four patients underwent
osteotomy at the age of 3 years, 4 months, 4 and 8 years
but the results are not documented. Krida [6] described
corrective osteotomy in three cases with postero-medial
bowing of the tibia at an early age. All the osteotomies
healed well, but one patient underwent an epiphysiodesis
for the limb length discrepancy and another patient had a
shortening of the limb by 2.5 cm at the age of 7 years.
Hofmann and Wenger [3], in their study of 13 cases,
treated all their patients conservatively, but advocated
the role of corrective osteotomy at an early age for severe
postero-medial bowing of the tibia. Their rationale was
that some length would be gained by straightening the

Fig. 4
Fracture through the regenerate.
tibia and some gain would occur by physeal stimulation.
They also reasoned that proper alignment of the physis in
a plane perpendicular to the axis of weight bearing would
allow resumption of normal physeal growth.
The role of osteotomy for nonresolving tibial intorsion in
postero-medial bowing has not been discussed in the
literature. There have been no reports on delayed healing
of the osteotomy in congenital postero-medial bowing of
the tibia. All patients who underwent osteotomy will re-
quire a surgery for limb lengthening, in view of the limb
length discrepancy at a later date. Hence we feel that it is
better to wait till the child attains an older age and observe
for serial correction of the angulation and intorsion.
Management of the limb length discrepancy in congenital
postero-medial bowing of the tibia and fibula with
contralateral epiphysiodesis has been described by various
authors [3,4,6,8]. We are not aware of any reports on limb
lengthening, except for Pappas’ description of an isolated
case in his series for partial correction of the limb length
discrepancy. The patient required a supplemental bone
graft and did not have any residual problems.
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Congenital postero-medial bowing of the tibia Johari et al. 483
Fig. 5
Atrophic regenerate during lengthening.
Contralateral epiphysiodesis was not an acceptable alter-
native in our patients because of parental concern about a
procedure, which interfered with the growth of the normal
leg and the eventual height of the patient. Although we
have no experience with this procedure for congenital
posteromedial bowing, it is an acceptable alternative to
perform a contralateral epiphysiodesis for a limb length
discrepancy of more than 2 cm. Limb lengthening with
the use of the Ilizarov fixator was the preferred method as
it enabled correction of the residual angular deformity along
with limb lengthening. The principles of multiapical defor-
mity correction must be adhered to while planning and
executing the surgery, frame configuration and distraction
lengthening [9]. In our series, the indications for limb
lengthening were a limb length discrepancy of more than
3 cm and a bowing deformity of more than 301 at or above
the age of 3 years. Our rationale for operating these patients
was that the bowing of more than 301 at or above the age
of 3 years was less likely to resolve completely and a limb
length discrepancy of 3 cm or more was difficult to manage
conservatively as a large shoe raise was cumbersome and
not tolerated by most children and compliance was also
a concern.
 484 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 6

When we analyzed the conservatively managed control
group, we found almost no difference in the angulation at
a follow-up of 9.5 years between the surgical and con-
servative groups, suggesting that the angulation will reduce
even without the surgery. Although we operated on the
Fig. 6
cases that had a more severe angulation, we retrospectively
feel that we could have waited for some more time before
the surgery. We believe that serial measurements annually
should be the main guideline to decide the timing of the
surgery and not a single measurement at a predecided
age. A rational approach would be to operate only if there
is a significant limb length discrepancy of more than 3 cm
and no decrease in the angulation for a period of 1–2 years
on serial X-rays. We believe that 3 years is not the optimal
age to operate on these children. It is better to wait till
the child is older (closer to puberty), can cooperate and

Fig. 7

45

40

35

30

25

20

15

10

0
0 9.5

Mean years
Medial angle Medial angle
Surgical n = 9 Conservative n = 11

Comparison of medial angulation between the surgical and

conservative groups. P value not significant at 0 and 9.5 years
Fibular nonunion. (P < 0.05).

Table 4 Conservatively managed control group

Age at Age at
presentation follow-up Presentation At age 3 years Last follow-up

Days, months, Years, Medial Posterior Medial Posterior LLD, Medial Posterior LLD, Follow-up since presentation
Patient years months angle angle angle angle cm angle angle cm (years, months)

C1 4+0+0 11 + 6 60 55 21 20 2.6 10 9 4.5 11 + 6

C2 0+2+0 5+0 45 25 21 18 2.7 10 15 4.0 4 + 10
C3 2+0+0 11 + 0 50 55 18 15 2.7 10 4 5.5 11 + 0
C4 0+0+1 10 + 0 28 23 10 9 2.4 5 5 1.5 9+0
C5 9+0+0 8+0 46 34 12 24 2.9 5 0 4.5 8+0
C6 4+0+0 5+6 40 42 15 8 1.5 8 8 2.5 5+6
C7 21 + 0 + 0 10 + 0 29 40 7 5 2.2 3 2 3.5 10 + 0
C8 0+2+0 13 + 6 47 60 28 26 2.9 8 6 4.0 13 + 6
C9 5+0+0 5+0 40 42 14 8 2.0 9 5 2.5 5+0
C10 0 + 11 + 0 10 + 11 38 36 12 10 2.0 8 6 3.0 10 + 0
C11 0+1+0 13 + 1 25 40 15 12 1.5 10 10 3.5 13 + 0
Mean 40.7 41 15.7 14.0 2.3 7.8 6.4 3.5
Standard 10.5 11.9 5.9 7 0.5 2.4 4 1.1
deviation

All angles in degrees.

LLD, limb length discrepancy.

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Fig. 8
50
45
40
35
30
25
20
15
10
5
0
0 9.5
Mean years
Posterior angle Posterior angle
Surgical n = 9 Conservative n = 11
Comparison of posterior angulation between the surgical and
conservative groups. P value not significant at 0 and 9.5 years
(P < 0.05).
there is a lower chance of complications with the use of
the Ilizarov fixator.
One patient who underwent a single-level osteotomy and
lengthening developed an atrophic regenerate at the
lengthening site and later developed an asymptomatic
fibular nonunion. We are of the opinion that a two-level
osteotomy with deformity correction at the distal osteo-
tomy and lengthening at the proximal osteotomy will
prevent such a complication from occurring. It also allows
for finer adjustments in the frame for deformity correction
and lengthening. The reduced working space in the small
legs in younger children makes a double-level osteotomy
difficult; in such cases a single-level osteotomy is unavoi-
dable. A fracture occurred in two cases after fixator removal.
Adequate precautions must be taken to guard against this
complication, including prolonged application of the frame
and dynamization of the frame before removal. As it is not
possible to control the activities of smaller children, the
risk of a fracture is omnipresent. Residual valgus angul-
ation occurred in five cases. The reason for this could be
the reduced growth occurring at the lateral part of the
distal tibial physis as has been reported earlier by Pappas
[4]. A slight overcorrection of the deformity at the time of
osteotomy taking into account the abnormal physeal
growth might have prevented the residual valgus angula-
tion from occurring. A plausible explanation for the post-
erior angulation, which occurred in two cases could be the
reduced growth occurring at the anterior portion of the
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Congenital postero-medial bowing of the tibia Johari et al. 485
Fig. 9
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
3 9.5
Mean years
Length discrepancy (cm) Length discrepancy (cm)
Surgical n = 6 Conservative n = 11
Comparison of limb length discrepancy between the surgical and
conservative groups. P value significant at 3 and 9.5 years (P < 0.05).
physis. Although there was an improvement in the mean
medial and posterior bowing and limb length discrepancy
with surgery, the incidence of complications was high,
especially in the younger patients. Early surgery and over
lengthening takes care of the length deficit for a period of
time. However the deficit recurs or returns within a couple
of years necessitating a second lengthening later, probably,
closer to skeletal maturity. We advocate a conservative
approach in these patients and a one-stage lengthening
surgery closer to skeletal maturity where the limb length
discrepancy can be dealt with and any residual angulation
corrected simultaneously. Meticulous attention is required
for the lengthening and deformity correction to normalize
the preexisting deformity and better the natural history.
Limitations of this study
The patients have not reached skeletal maturity and a
longer follow-up is required. The measurement of tibial
intorsion was difficult to quantify radiologically. Although
the operated and conservatively treated groups have been
compared, the two groups were not similarly matched with
respect to early angulation as the operated group had more
severe angulation, which in fact was the criterion for
surgical correction.
Conclusion
We conclude that early surgery for congenital postero-
medial bowing of the tibia and fibula is fraught with com-
plications and needs meticulous attention to detail. We
 486 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 6
recommend that surgery should be delayed till the child is
older, preferably near to skeletal maturity, for a limb length
discrepancy of more than 3 cm with no improvement in
angulation on serial measurements.
References
1 Heyman CH, Herndon CH. Congenital posterior angulation of the tibia.
J Bone Joint Surg (Am) 1949; 31:571–580.
2 Heyman CH, Herndon CH, Heiple KG. Congenital posterior angulation
of the tibia with talipes calcaneus. J Bone Joint Surg (Am) 1959;
41:476–488.
3 Hofmann A, Wenger DR. Postero-medial bowing of the tibia. J Bone Joint
Surg (Am) 1981; 63:384–388.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4 Pappas AM. Congenital postero-medial bowing of the tibia and fibula.
J Paediatr Orthop 1984; 4:525–531.
5 Miller BF. Congenital posterior bowing of the tibia with talipes
calcaneo-valgus. J Bone Joint Surg (Br) 1951; 33:50–55.
6 Krida A. Congenital posterior angulation of the tibia: a clinical entity not
related to pseudarthrosis. Am J Surg 1951; 82:98–102.
7 Shah HH, Doddabasappa SN, Joseph B. Congenital posteromedial bowing
of the tibia: a retrospective analysis of growth abnormalities in the leg.
J Paediatr Orthop B 2009; 18:120–128.
8 Rathgeb JM, Ramsey PL, Cowell HR. Congenital kyphoscoliosis of the tibia.
Clin Orthop 1974; 103:178–190.
9 Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs:
preoperative planning of multiapical frontal plane angular and bowing
deformities of the femur and tibia. Clin Orthop 1992; 280:65.