Tibial Bowing Workup

  • Author: James J McCarthy, MD, FAAOS, FAAP; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Feb 6, 2012
 

Laboratory Studies

  • No studies are necessary other than radiographic images unless concern exists regarding the diagnosis, in which case other studies (eg, a metabolic study to assess for rickets) may be ordered.
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Imaging Studies

  • Initial evaluation
    • The initial evaluation should include an anteroposterior (AP) radiograph of the lower extremity with a ruler to measure limb length and to assess the deformity.
    • Hip dysplasia, although not normally seen in patients with this disorder, can be assessed at age 6-12 weeks.
    • Obtain a lateral radiograph of both tibiae.
    • Obtain radiographs of the foot if the foot fails to correct by age 4-6 weeks. This should include AP and lateral views of the foot and a plantarflexion lateral view of the foot to assess for a vertical talus.
  • Limb-length inequality at skeletal maturity must be assessed before any type of limb equalization procedure (epiphysiodesis, lengthening, or shortening) is performed.[21, 22]
    • Typically, an epiphysiodesis is required at about age 11 years in females and age 13 years in males, but this varies depending on the patient's skeletal age and the degree of the limb-length inequality.
    • Epiphysiodesis can be indicated as early as age 8 years. As mentioned previously, if the degree of limb inequality is large (>5 cm) and the patient is not expected to be tall, a lengthening may be considered.
    • Limb-length inequality at skeletal maturity is most reliably predicted from a series of at least 3 radiographs taken at least 6 months apart.
  • Various radiographic measures have been used to determine limb-length inequality.
    • The teleoroentgenogram is a single-exposure AP radiograph of the lower extremity with a ruler. This study is subject to a magnification error of 5-10% at the outer border of the film but has the advantage of showing coronal (angular) deformities and is not subject to movement errors.
    • Orthoradiography incorporates 3 separate exposures (hip, knee, and ankle) in an effort to avoid magnification errors.[23]
    • Scanography, shown in the image below, uses a similar technique, but exposure size is reduced and all 3 exposures are on 1 film cassette. Scanogram of a patient with posteromedial tibial bScanogram of a patient with posteromedial tibial bowing and a limb-length inequality.
    • Both orthoradiography and scanography are subject to movement errors, and angular deformities cannot be assessed.
    • All of the techniques are inaccurate if the patient has knee or hip flexion contractures or if the patient is simply flexing the knee or hip asymmetrically at the time of exposure. If the knee appears as a tunnel view, there is undoubtedly a significant degree of knee flexion. Lateral radiographs or separate (prone) radiographs of the femur and tibia with a radiopaque ruler can be obtained to assess limb length in patients with knee flexion contractures.
    • The use of computed tomography (CT) scanning to assess limb length has increased. CT scanning uses less radiation and is more accurate than conventional radiographic techniques in patients with knee or hip flexion contractures.[24]
    • Ultrasound is now being used as well, primarily as a screening tool.[25]
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Diagnostic Procedures

  • Once the current limb-length inequality has been measured, a prediction of the ultimate limb-length inequality at skeletal maturity is needed to determine treatment.[26, 20] There are 3 methods typically used to do this: the arithmetic method, the growth-remaining curve, and the Moseley straight-line graph.[27] A fourth method, known as the multiplier method, uses an arithmetic formula to determine limb inequality at maturity.[28, 29, 30]
    • The simplest method is the arithmetic method. This method assumes growth of the distal femur to be 1 cm per year, the growth of the proximal tibia to be 0.6 cm per year, and that boys reach skeletal maturity at age 16 years and girls at age 14 years.
    • The growth-remaining curve relates chronologic age to limb length to determine a child's growth percentile. Using this, the remaining growth of the tibia or femur can be determined graphically.
    • The advantage of the Moseley straight-line graph, which combines information from both the arithmetic method and the growth-remaining curve, is that several measurements (preferably at least 3, separated by 6 months) can be plotted on 1 graph. The Moseley straight-line graph relies on determination of the bone age as estimated from a left hand/wrist film.
    • When these 3 techniques (ie, arithmetic method, growth-remaining curve, Moseley straight-line graph) were evaluated, the accuracy rates of these 3 methods showed little significant difference.
    • The multiplier method simply takes the current limb-length inequality and multiplies it by a constant listed in a table by chronologic age. Timing of the epiphysiodesis can then be estimated by use of an arithmetic formula to determine limb-inequality at maturity. It is as precise as other methods for determining limb length at maturity and can accurately estimate the timing for epiphysiodesis.
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Histologic Findings

The histology of posteromedial bowing is unknown, but animal studies performed to model angular deformities demonstrate increased trabecular bone formation in the area of the apex of the angular deformity, with no new cartilage cells, and subepiphyseal bone condensation with subsequent thinning of the epiphyseal plate.

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Contributor Information and Disclosures
Author

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: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Fixes-4-kids Ownership interest Consulting; Lippincott Williams and WIcins Royalty Editing textbook; OERHOPEDICS Royalty Editor

Specialty Editor Board

Dennis P Grogan, MD  Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

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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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