Report of a Case of Genu Recurvatum Following Tibial Eminence Avulsion Treated by Proximal Tibial Flexion Osteotomy and Review of the Literature

doi:10.4236/ss.2011.23023

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Surgical Science, 2011, 2, 117-120

doi:10.4236/ss.2011.23023 Published Online May 2011 (http://www.scirp.org/journal/ss)

Report of a Case of Genu Recurvatum Following Tibial

Eminence Avulsion Treated by Proximal Tibial Flexion

Osteotomy and Review of t he Literature

Nima Heidari1, James A. G. Madden2, Mark D. Loeffler1

1Colchester General Hospital, Turner Road, Colchester, Essex, UK

2Bart’s and the London School of Medicine and Dentistry, London, UK

E-mail: [email protected]

Received January 9, 2011; revised March 30, 2011; accepted April 11, 2011

Abstract

We report a case of acquired genu recurvatum treated with a proximal tibial flexion osteotomy. A partial

growth arrest at the anterior portion of the proximal tibial physis following a conservatively treated

Meyers-McKeever type II injury of the tibial eminence. This is a reliable method in the correction of genu

recurvatum. By using tricortical autogenous iliac crest graft, the osteotomy may be made very stable in-

tra-operatively circumventing the need for fixation.

Keywords: Genu Recurvatum, Flexion Osteotomy, Proximal Tibial Growth Arrest, Knee Pain

1. Introduction

Genu recurvatum is the hyperextension of the tibia in rela-

tion to the femur. Once this angle exceeds 15 degrees and

the patient is symptomatic, surgical treatment options may

be explored [1]. The deformity may cause knee instability,

pain [2] and be associated with shortening of the limb [3,4].

This condition may be congenital or acquired. Three types

have been described: an osseous proximal tibial deformity,

soft tissues involving capsule-ligamentous structures and

cases where a combination of the two exist [1,5,6]. The

association of proximal tibial physeal injuries leading to

partial growth arrest and genu recurvatum is well described

in the literature [4,7-10].

There are a variety of treatment methods described in-

cluding bracing to limit the hyper extension, soft tissue

procedures [3], especially in cases of capsuloligamentous

laxity, which have now fallen out of favour due to recur-

rence of deformity and pain and arthroereisis [11,12],

which is now of historic interest. Flexion osteotomies of

the proximal tibia have been described for bony as well as

capsuloligamentous aetiologies [1,6,13,14].

2. Case Report

A nine year old girl was involved in a road traffic acci-

dent sustaining a multitude of injuries. Only injuries of

her left knee will be discussed here. These included

Meyers-McKeever [15] type 2 injury of the tibial spine

and avulsion of the tibial attachment of the medial col-

lateral ligament (MCL). Following a good recovery from

the accident, she underwent arthroscopy and open repair

of the MCL four months after the original injury. The

tibial spine fracture was found to have healed but the

medial joint laxity necessitated an open repair of the

tibial attachment of the medial collateral ligament. At

arthroscopy her minsci were noted to be intact and the

articular surfaces of her knee normal. She went on to

make and uneventful recovery from this. At clinical re-

view aged 12, she was noted to be taking part in some

sporting activities. Clinical examination revealed grade 2

laxity of the ACL and MCL with definitive end points.

At clinical review aged 13 she complained of anterior

knee pain and had reduced her sporting activities due to

instability of her knee. On examination she had devel-

oped a recurvatum and her radiographs revealed an ante-

rior tibial growth arrest with a tibial recurvatum angle of

68.9 degrees [1,16] (Figure 1). Aged 14, following the

closure of her proximal tibial physis, a proximal tibial

opening wedge osteotomy was performed to correct the

tibial deformity. Clinically the preoperative range of

movement of the affected knee was −25 (recurvatum) to

130 degrees.

In order to correct the recurvatum an opening wedge

N. HEIDARI ET AL.

118

proximal tibial flexion osteotomy was performed

proximal to the tibial tuberosity. A midline incision was

made over the patella tendon, with the proximal tibia

exposed medially and laterally. Two guide wires were

inserted at the level of the osteotomy which was just

above the tibial insertion of the patella tendon and

sloping slightly distally and posteriorly to avoid a frac-

ture of the plateau. A saw and broad osteotome were

used for the osteotomy, leaving the posterior cortex of

the tibia intact. Wedges from the Puddu plate set were

used to open the osteotomy anteriorly by 12 mm. The

osteotomy was held in place by impacting three tricor-

tical triangles of autogenous bone graft, from the pa-

tient’s iliac crest, with a punch. Upon completion of

this manoeuvre the osteotomy was felt to be very stable

so as not to require additional internal fixation. Post

operatively she was immobilised in a cylinder cast at 10

degrees of flexion for two weeks. Active and passive

range of motion and strengthening exercises were

started following the removal of the cast at two weeks

post operatively. She remained non weight bearing until

signs of bony union were visible at eight weeks. After

the correction, the tibial recurvatum angle was 88.3

degrees (Figure 2). This was maintained at the final

follow up 18 months post operatively with evidence of

graft incorporation at the osteotomy site. The range of

movement was 0 to 140 degrees.

Figure 1. Preoperative lateral radiograph of the knee dem-

onstrating a tibial recurvatum angle of 68.9 degrees.

3. Discussion

Acquired genu recurvatum may be a debilitating condi-

tion. It is frequently associated with anterior knee pain [2],

instability [6] and weakness as well as limb shortening

[3,4] when the condition is unilateral. Genu recurvatum

occurring at the knee may be due to altered osseous

anatomy, abnormality of the capsuloligamentous struc-

tures or a combination of both [1,6,16].

A variety of soft tissue operations have been described

for predominantly capsuloligamentous insufficiency.

These are best reported in cases of poliomyelitis. Heyman

in 1924 [17] described transplanting the femoral attach-

ments of the medial and lateral collateral ligaments more

posteriorly in order to provide a check rein to hyperexten-

sion. He later modified this by including a posterior liga-

mentous reinforcement by using a strip of fascia lata or

the peroneous longus and brevis tendons as a free graft

[18,19]. Gill has also described a similar procedure using

a strip of fascia lata as a posterior check rein ligament

[20]. More recently Perry et al. [3] have published on a

technique of triple tenodesis which is a complex soft tis-

sue procedure involving proximal advancement of the

posterior capsule as well as creation of midline posterior

check rein using tendons of gracilis, semitendinosous,

biceps femoris and a sling of fascia lata.

Figure 2. Postoperative lateral radiograph of the knee dem-

onstrating a tibial recurvatum angle of 86.5 degrees.

N. HEIDARI ET AL. 119

Unfortunately these procedures are compromised by

the long term sequelae of the repairs stretching and the

recurrence of the deformity.

The concept of arthroereisis has also been described.

Campbell [21] proposed the implantation of the patella

into the proximal tibia. Mayer [11] subsequently modified

this technique by using a cortical graft for the same pur-

pose. These procedures are now of historic interest. Al-

though good results have been reported [12] this proce-

dure is complicated by pain and failure of the graft

through fracture or resorption [3].

The reported case in this paper illustrates growth arrest

at the anterior portion of the proximal tibial physis due to

an injury, which brings about a recurvatum deformity of

the tibial plateau. The association of proximal tibial phy-

seal injury and subsequent angular deformities is well

established [4,7-10]. In the case presented here there was

a Meyers-McKeever II lesion of the tibial eminence as

well as a medial collateral ligament avulsion. This does

represent a high energy injury to the knee which may well

include an undiagnosed Salter-Harris V injury. No cases

of growth arrest have been reported in association with a

conservatively managed tibial eminence fracture to our

knowledge and this case may represent the first of such.

Proximal tibial osteotomies have been described for the

treatment of adult genu recurvatum. These can take the

form of an anterior opening wedge or posterior closing

wedge osteotomies. These have the effect of increasing

the posterior slope of the tibial plateau therefore correct-

ing the deformity. Lexer in 1931 published an opening

wedge tibial osteotomy proximal to the tibial tubercle.

This was independently reported by Brett [14] in 1935

and subsequently modified by Sutherland and Rowe [22]

who used stainless steel wedges in place of autologous

bone graft as proposed by Brett in order to avoid loss of

correction through the collapse of the graft. More recently

the detachment and proximal transposition of the tibial

tubercle was suggested by Lecuire [6] to avoid the possi-

ble complication of patella baja. Moroni et al. [1] re-

ported on 27 cases of genu recurvatum managed with an

opening wedge osteotomy with or without tibial tubercle

reattachment with excellent to fair results in both osseous

and capsuloligamentous aetiologies. An alternative clos-

ing wedge osteotomy proximal to the tibial tubercle with

anterior displacement to treat osseous genu recurvatum

has also been described and good results have been re-

ported [23]. Both opening [24,25] and closing wedge os-

teotomies have been reported distal to the tibial tubercle.

These have the disadvantages of causing a large bony

prominence over the anterior border of the tibia [13] and

requiring a fibular osteotomy to achieve the correction.

The method of fixation following the corrective os-

teotomy varies in the literature. These include dual but-

tress plating [26], plates [1], Steinmann pins and plaster

[23] and plaster only [13,14]. Other authors have em-

ployed the use of the circular frame for the gradual cor-

rection and consolidation of the osteotomy [24,25,27].

We did not use any form of fixation. The use triangular

wedges of tricortical graft impacted in to the osteotomy

proved very stable. Plaster cast immobilisation was used

for the first two weeks to allow for wound healing and

comfort in the immediate post operative period. Upon

removal of the plaster the knee was mobilised to avoid

stiffness but weight bearing was not commenced until

signs of union were apparent at the osteotomy site some

eight weeks post operatively.

Anterior opening wedge osteotomy has been shown to

affect the biomechanics of the knee joint. Agneskirchner

[28] et al. in a cadaveric study showed that in a knee with

intact ligaments a high tibial flexion osteotomy increases

cartilage contact pressure anteriorly. There is also anterior

and superior translation of the tibia on the femur. This

was shown to counteract the posterior translation seen in

a PCL deficient knee both in extension and flexion. In

fact the authors advocated its use in posteromedial carti-

lage damage and posterolateral instability. In a study by

Rodner et al. [29] the effect of increased posterior tibial

slope, beyond the physiological norm, in an ACL-defi-

cient knee resulted in redistribution of the contact pres-

sure posteriorly. This demonstrates the need for a full

assessment prior to an osteotomy including arthroscopy

[30].

We feel that the opening wedge flexion osteotomy of

the tibia proximal to the tibial tubercle is a reliable

method in the correction of genu recurvatum. By using

tricortical autogenous iliac crest graft, the osteotomy may

be made very stable circumventing the need for fixation.

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