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Tibial Bowing Treatment & Management

  • Author: James J McCarthy, MD, FAAOS, FAAP; Chief Editor: Thomas M DeBerardino, MD  more...
Updated: Apr 11, 2016

Approach Considerations

Initial treatment of the tibial bowing foot deformity includes stretching, serial casting, or splinting. The bowing deformity rapidly corrects. A 50% correction is usually seen by age 2 years, though a mild deformity often persists. The rationale for corrective tibial osteotomy is less clear, as a tibial osteotomy is rarely indicated; however, a significant deformity that interferes with development, especially if little or no correction is seen by age 2 years or a symptomatic and persistent deformity is seen in children older than 10 years, may be an indication for tibial osteotomy.[29]

Performing a tibial osteotomy does not seem to decrease the need for later limb equalization. Most children with posteromedial bowing will require a limb equalization procedure. The type of procedure depends on the degree of projected limb-length inequality at skeletal maturity. Typically, limb-length inequality is 2-6 cm at skeletal maturity. Usually, an appropriately timed epiphysiodesis can restore limb-length equality, although a lengthening procedure may be indicated for more severe projected limb-length inequalities (>5 cm), especially in children of short stature.[30, 24, 31]

Understanding the nature of the deformity and establishing the correct diagnosis are very important. Tibial osteotomies in children with anterolateral deformities can be disastrous. This type of tibial deformity can be associated with persistent pseudarthrosis even without any surgical procedures, and performing an osteotomy may promote or instigate an early nonunion. If the patient has a metabolic etiology for their bowing, treat the metabolic disorder before considering surgical options. Posteromedial bowing typically self-resolves, leaving only the limb-length inequality to be addressed.

Experimental methods of producing lengthening, such as cultured chondrocytes transfer, vascular surgery,[32] and periosteal sleeve resection,[33] are being studied.


Medical Therapy

Currently, no medical therapies exist for limb-length inequality. Nonsurgical treatment includes stretching, serial casting, or splinting. This should be initiated at birth. If significant correction is not obtained by age 4-6 weeks, question the diagnosis; the possibility of a more serious foot deformity, such as a vertical talus, must be ruled out radiographically. After the foot has fully corrected, a splint can be made to maintain correction until age 12-24 months. Bracing of the bowing deformity has been suggested, but it is not currently believed to significantly alter the natural history.[34]

Most children with posteromedial tibial bowing have a limb-length inequality averaging 3 cm, but this can range from about 2 cm to 6 cm. Typically, a limb-length inequality of 2 cm or less is not a functional problem. Often, limb length can be equalized with a shoe lift. About two thirds of limb-length inequalities are corrected with a lift; up to 1 cm can be inserted in the shoe. Larger limb-length inequalities require the shoe to be built up. This is necessary for every shoe worn and limits the type of shoe that the patient can wear.

Limb-length inequalities of more than 5 cm are difficult to treat with a shoe lift. The shoe looks unsightly, and often the patient complains of instability with such a large lift. A foot-in-foot prosthesis can be used for larger limb-length inequalities. This is often a temporizing measure for very young children with significant limb-length inequalities. The prosthesis is bulky, and a fixed equinus contracture may result.


Surgical Therapy

The type of surgical treatment depends on the degree of projected limb-length inequality at skeletal maturity. Epiphysiodesis is a reliable procedure that inhibits growth with few complications. It cannot be performed on patients who are skeletally mature, and the final limb-length inequality and the degree of growth inhibition must be predicted and are subject to error. In addition, epiphysiodesis effectively shortens the longer leg and is a procedure that is usually performed on the uninvolved side, both of which may be unappealing to the patient and family. Typically, predicted limb-length inequalities of 2-6 cm can be corrected with an appropriately timed epiphysiodesis.[35, 36]

Lengthening is usually performed with corticotomy and gradual distraction. This technique can result in an increase of 25% or more in bone length, but typically a lengthening of 15% (or about 6 cm) is recommended. The limits of lengthening depend on patient tolerance, bony consolidation, maintenance of joint range of motion, and stability of the joints above and below the lengthened limb.[37, 38, 39]

Procedural details

Predicted limb-length inequality at skeletal maturity must be carefully assessed, and the effect of the given procedure on future growth must be estimated. Estimated height is also important, especially with a large limb-length inequality, because this may determine whether epiphysiodesis or lengthening should be performed. Preoperative teaching is important, especially for lengthening procedures that can last several months and require a great deal of tolerance and cooperation from the patient and family.

The bone is typically lengthened about 1 mm/day, after a 7-10 day latency period. The total time in the fixator is about 1 month per 1 cm (10 mm) of lengthening and includes both the time to lengthen and time for the bone to consolidate and become strong enough to bear weight.

Numerous fixation devices are available for lengthening, such as the ring fixator with fine wires, the monolateral fixator with half pins, and the hybrid frame. The choice of fixation device depends on the desired goal.[40, 41]

A monolateral device is easier to apply and is better tolerated by the patient. The disadvantages of monolateral fixation devices include the following: limitation of the degree of angular correction that can be obtained concurrently; the cantilever effect on the pins, which may result in angular deformity, especially when lengthening the femur in large patients; and adjustments are difficult to make without placing new pins. Monolateral fixators and circular fixators appear to have similar success rates, especially with more modest lengthenings of 20% or less.

Self-lengthening (automated) intramedullary rods can also be used to gain length, without the need of external fixation. Care must be taken not to injure the growth plates in skeletally immature patients. Complication rates are similar to lengthening with external fixation, but patients tend to tolerate these implants better.


Postoperative Care

Postoperative care is minimal for patients who have an epiphysiodesis. Knee range of motion (ROM) should be monitored.[42, 43] Full extension and 90° of flexion should be obtained by 2 weeks after surgery. Weightbearing can begin immediately, and the patient can return to sports at 6-12 weeks.

Postoperative care for patients undergoing lengthening with an external fixator or automated self-lengthening nails is quite demanding. Lengthening begins 5-7 days postoperatively and continues at 1 mm/day until the desired length is obtained. Careful assessment of the joints adjacent to the fixator is mandatory in order to assess for ROM and joint subluxation.



Epiphysiodesis has been reported to result in physeal closure in 85-100% of patients with few complications. In the author's review[44] of 44 patients who underwent proximal tibial epiphysiodesis, no complications occurred, though lack of growth inhibition, angular deformity, and knee stiffness can occur.[45]

Numerous complications can occur when performing limb-lengthening procedures, even in experienced hands.[46] Complication rates vary significantly among reported studies and seem to depend on the degree of lengthening, definition of complication, and the surgeon's experience. Complication rates from most series, including that of the authors,[44, 47] are about one per procedure, and many of these require operative treatment. Fortunately, the ultimate objective can usually still be obtained.

The most common complication is pin-site infection. Depending on how this complication is diagnosed, treated, and reported, it may occur in nearly every patient. Numerous pin-care protocols have been developed. Some authors are demonstrating good success with a shower regimen after the incisions have healed. This author uses this regimen in combination with standard cleaning of the pin sites and oral antibiotics if excessive discharge, redness, or swelling is present. Periosteal reaction occurs around the pin sites in most patients, and this may be an early indication of loosening.

Newer pins, coated with hydroxyapatite, have improved fixation to bone and may reduce the rate of infection and loosening during external fixation for distraction osteogenesis. Use of hydroxyapatite-coated pins should be considered in clinical situations requiring prolonged external fixation.

Knee ROM decreases uniformly in femoral lengthening by an average of 37°, but at follow-up, the mean loss in ROM is usually minimal.

Other, more ominous complications include fracture, osteomyelitis, and joint subluxation. The incidence of these more serious complications is about 25% with an experienced surgeon.

Less commonly considered effects of limb lengthening include muscle weakness, pain, and possible physeal inhibition. The last effect is extremely important if lengthening procedures are planned for younger patients with an open physis. Some reports, including this author's,[44] found little difference in prelengthening and postlengthening growth velocities, indicating little effect of lengthening on the adjacent growth plates (with moderate lengthenings). Other reports have found growth inhibition, especially in the tibia and in children after extensive lengthening procedures (> 30%).[48]

Unlike pain associated with conventional surgery, pain with lengthening seems to continue beyond the postoperative period and through the lengthening and consolidation phases, until the fixator is removed.

The use of somatosensory evoked potential (SEP) monitoring may be helpful in preventing neurologic injuries, especially of the peroneal nerve. The use of ultrasound,[49] electrical stimulation,[50] or both, while not routinely prescribed, may decrease the time to consolidation.


Long-Term Monitoring

Continued monitoring of limb-length inequality is needed for patients undergoing an epiphysiodesis. An orthoroentgenogram or scanogram should be taken every 6 months until skeletal maturity. The expected goal is limb-length equality within 1 cm at skeletal maturity.

For patients undergoing limb lengthening, the fixator can sometimes be removed in an outpatient setting, but usually these devices are removed with the patient under sedation.

Contributor Information and Disclosures

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

  1. Schoenecker PL, Rich MM. The lower extremity. J Pediatr Orthop. 2001. 1092-95.

  2. Stevenson DA, Viskochil DH, Schorry EK, Crawford AH, D'Astous J, Murray KA, et al. The use of anterolateral bowing of the lower leg in the diagnostic criteria for neurofibromatosis type 1. Genet Med. 2007 Jul. 9(7):409-12. [Medline].

  3. Heyman CH, Herndon CH, Heiple KG. Congenital posterior angulation of the tibia with talipes calcaneus; a long-term report of eleven patients. J Bone Joint Surg Am. 1959 Apr. 41-A(3):476-88. [Medline].

  4. Hofmann A, Wenger DR. Posteromedial bowing of the tibia. Progression of discrepancy in leg lengths. J Bone Joint Surg Am. 1981 Mar. 63(3):384-8. [Medline].

  5. Lemire EG. Congenital anterolateral tibial bowing and polydactyly: a case report. J Med Case Reports. 2007 Jul 23. 1:54. [Medline].

  6. Phemister D. Operative arrestment of longitudinal growth in the treatment of deformities. J Bone Joint Surg. 1933. 15A:1.

  7. Scott AC, Urquhart BA, Cain TE. Percutaneous vs modified phemister epiphysiodesis of the lower extremity. Orthopedics. 1996 Oct. 19(10):857-61. [Medline].

  8. Gabriel KR, Crawford AH, Roy DR. Percutaneous epiphysiodesis. J Pediatr Orthop. 1994 May-Jun. 14(3):358-62. [Medline].

  9. Codivilla A. On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. 1904. Clin Orthop Relat Res. 1994 Apr. 4-9. [Medline].

  10. Curran AR, Kuo KN, Lubicky JP. Simultaneous ipsilateral femoral and tibial lengthening with the Ilizarov method. J Pediatr Orthop. 1999 May-Jun. 19(3):386-90. [Medline].

  11. Young N, Bell DF, Anthony A. Pediatric pain patterns during Ilizarov treatment of limb length discrepancy and angular deformity. J Pediatr Orthop. 1994 May-Jun. 14(3):352-7. [Medline].

  12. Johari AN, Dhawale AA, Salaskar A, Aroojis AJ. Congenital postero-medial bowing of the tibia and fibula: is early surgery worthwhile?. J Pediatr Orthop B. 2010 Nov. 19(6):479-86. [Medline].

  13. Alaseirlis DA, Korompilias AV, Beris AE, Soucacos PN. Residual malformations and leg length discrepancy after treatment of fibular hemimelia. J Orthop Surg Res. 2011 Sep 27. 6:51. [Medline]. [Full Text].

  14. Dawson GR. Intra-uterine fractures of the tibia and fibula. J Bone Joint Surg. 1949. 31A:406-8.

  15. Pappas AM. Congenital posteromedial bowing of the tibia and fibula. J Pediatr Orthop. 1984 Sep. 4(5):525-31. [Medline].

  16. Maffuli N, Fixsen JA. Distraction osteogenesis in congenital limb length discrepancy: a review. J R Coll Surg Edinb. 1996 Aug. 41(4):258-64. [Medline].

  17. Noonan KJ, Leyes M, Forriol F. Distraction osteogenesis of the lower extremity with use of monolateral external fixation. A study of two hundred and sixty-one femora and tibiae. J Bone Joint Surg Am. 1998 Jun. 80(6):793-806. [Medline].

  18. Sabharwal S, Zhao C, McKeon J, et al. Reliability analysis for radiographic measurement of limb length discrepancy: full-length standing anteroposterior radiograph versus scanogram. J Pediatr Orthop. 2007 Jan-Feb. 27(1):46-50. [Medline].

  19. Sabharwal S, Zhao C, McKeon JJ, et al. Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram. J Bone Joint Surg Am. 2006 Oct. 88(10):2243-51. [Medline].

  20. Aaron A, Weinstein D, Thickman D. Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am. 1992 Jul. 74(6):897-902. [Medline].

  21. Minty I, Maffulli N, Hughes TH. Radiographic features of limb lengthening in children. Acta Radiol. 1994 Nov. 35(6):555-9. [Medline].

  22. Terjesen T, Benum P, Rossvoll I. Leg-length discrepancy measured by ultrasonography. Acta Orthop Scand. 1991 Apr. 62(2):121-4. [Medline].

  23. Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999 May-Jun. 7(3):143-53. [Medline].

  24. Westh RN, Menelaus MB. A simple calculation for the timing of epiphysial arrest: a further report. J Bone Joint Surg Br. 1981 Feb. 63-B(1):117-9. [Medline].

  25. Moseley CF. A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am. 1977 Mar. 59(2):174-9. [Medline].

  26. Aguilar JA, Paley D, Paley J, et al. Clinical validation of the multiplier method for predicting limb length discrepancy and outcome of epiphysiodesis, part II. J Pediatr Orthop. 2005 Mar-Apr. 25(2):192-6. [Medline].

  27. Aguilar JA, Paley D, Paley J, et al. Clinical validation of the multiplier method for predicting limb length at maturity, part I. J Pediatr Orthop. 2005 Mar-Apr. 25(2):186-91. [Medline].

  28. Paley D, Bhave A, Herzenberg JE. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000 Oct. 82-A(10):1432-46. [Medline].

  29. Viehweger E, Pouliquen JC, Kassis B. Bone growth after lengthening of the lower limb in children. J Pediatr Orthop B. 1998 Apr. 7(2):154-7. [Medline].

  30. Timperlake RW, Bowen JR, Guille JT. Prospective evaluation of fifty-three consecutive percutaneous epiphysiodeses of the distal femur and proximal tibia and fibula. J Pediatr Orthop. 1991 May-Jun. 11(3):350-7. [Medline].

  31. Johari AN, Dhawale AA, Salaskar A, Aroojis AJ. Congenital postero-medial bowing of the tibia and fibula: is early surgery worthwhile?. J Pediatr Orthop B. 2010 Nov. 19(6):479-86. [Medline].

  32. Belov S. Correction of lower limbs length discrepancy in congenital vascular- bone diseases by vascular surgery performed during childhood. Semin Vasc Surg. 1993 Dec. 6(4):245-51. [Medline].

  33. D'Souza H, Shah NM. Circumferential periosteal sleeve resection: results in limb-length discrepancy secondary to poliomyelitis. J Pediatr Orthop. 1999 Mar-Apr. 19(2):215-21. [Medline].

  34. Ofluoglu O, Davidson RS, Dormans JP. Prophylactic bypass grafting and long-term bracing in the management of anterolateral bowing of the tibia and neurofibromatosis-1. J Bone Joint Surg Am. 2008 Oct. 90(10):2126-34. [Medline].

  35. Ogilvie JW, King K. Epiphysiodesis: two-year clinical results using a new technique. J Pediatr Orthop. 1990 Nov-Dec. 10(6):809-11. [Medline].

  36. Porat S, Peyser A, Robin GC. Equalization of lower limbs by epiphysiodesis: results of treatment. J Pediatr Orthop. 1991 Jul-Aug. 11(4):442-8. [Medline].

  37. Hope PG, Crawfurd EJ, Catterall A. Bone growth following lengthening for congenital shortening of the lower limb. J Pediatr Orthop. 1994 May-Jun. 14(3):339-42. [Medline].

  38. Karger C, Guille JT, Bowen JR. Lengthening of congenital lower limb deficiencies. Clin Orthop. 1993 Jun. (291):236-45. [Medline].

  39. Paley D. Current techniques of limb lengthening. J Pediatr Orthop. 1988 Jan-Feb. 8(1):73-92. [Medline].

  40. Pommer A, Muhr G, David A. Hydroxyapatite-coated Schanz pins in external fixators used for distraction osteogenesis : a randomized, controlled trial. J Bone Joint Surg Am. 2002 Jul. 84-A(7):1162-6. [Medline].

  41. Siffert RS. The effect of staples and longitudinal wires on epiphyseal growth; an experimental study. J Bone Joint Surg Am. 1956 Oct. 38-A(5):1077-88. [Medline].

  42. Herzenberg JE, Scheufele LL, Paley D. Knee range of motion in isolated femoral lengthening. Clin Orthop. 1994 Apr. (301):49-54. [Medline].

  43. Kaljumae U, Martson A, Haviko T. The effect of lengthening of the femur on the extensors of the knee. An electromyographic study. J Bone Joint Surg Am. 1995 Feb. 77(2):247-50. [Medline].

  44. McCarthy JJ, Kim H, Saluan P. The effects of limb lengthening on growth. J Pediatr Orthop B. 2003 Sep. 12(5):328-31. [Medline].

  45. Little DG, Nigo L, Aiona MD. Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop. 1996 Mar-Apr. 16(2):173-9. [Medline].

  46. Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop. 1994 Apr. (301):10-8. [Medline].

  47. McCarthy JJ, Glancy GL, Chnag FM. Fibular hemimelia: comparison of outcome measurments after amputation and lengthening. J Bone Joint Surg Am. 2000 Dec. 82-A(12):1732-5. [Medline].

  48. Sharma M, MacKenzie WG, Bowen JR. Severe tibial growth retardation in total fibular hemimelia after limb lengthening. J Pediatr Orthop. 1996 Jul-Aug. 16(4):438-44. [Medline].

  49. Ehrlich MG, Eberson C, Hogan K. The effect of low intensity ultrasound stimulation on consolidation of the regenerate zone in a rat model of distraction osteogenesis. Presented at: Annual Meeting of the Pediatric Orthopaedic Society of North. America; May 2000. Vancouver, BC, Canada:

  50. Makarov MR, Delgado MR, Birch JG. Intraoperative SSEP monitoring during external fixation procedures in the lower extremities. J Pediatr Orthop. 1996 Mar-Apr. 16(2):155-60. [Medline].

Anteroposterior radiograph of a 1-year-old child with posteromedial tibial bowing.
Lateral radiograph of a 1-year-old child with posteromedial tibial bowing.
Anteroposterior and lateral radiograph of a 9-year-old child with posteromedial tibial bowing. Note that the bowing has significantly improved.
Posteromedial tibial bowing. The Galeazzi test. Note the difference in the height of the flexed knees.
Scanogram of a patient with posteromedial tibial bowing and a limb-length inequality.
A hydroxyapatite-coated Schanz pin used to secure external fixator devices to the bone.
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