Surgical Science, 2011, 2, 117-120
doi:10.4236/ss.2011.23023 Published Online May 2011 (http://www.scirp.org/journal/ss)
Copyright © 2011 SciRes. 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
Received January 9, 2011; revised March 30, 2011; accepted April 11, 2011
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
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 . The deformity may cause knee instability,
pain  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 , 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  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
In order to correct the recurvatum an opening wedge
N. HEIDARI ET AL.
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.
Acquired genu recurvatum may be a debilitating condi-
tion. It is frequently associated with anterior knee pain ,
instability  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  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
. More recently Perry et al.  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.
Copyright © 2011 SciRes. SS
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  proposed the implantation of the patella
into the proximal tibia. Mayer  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  this proce-
dure is complicated by pain and failure of the graft
through fracture or resorption .
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  in 1935
and subsequently modified by Sutherland and Rowe 
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  to avoid the possi-
ble complication of patella baja. Moroni et al.  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 . 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  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 , plates , Steinmann pins and plaster
 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
 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.  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
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
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