Surgical Technique

Tibial tubercle transfer improves patellar position and patellofemoral pain

Tibial tubercle osteotomy, which was popularized by John P. Fulkerson, MD, when used for anterior medialization, has dramatically changed how patellofemoral pain is treated. The goal of tibial tubercle transfer is to improve patellar position so it reduces patella alta and/or lateral patellar tracking (Figure 1).

Tibial tubercle osteotomy can be carried out in various angles. The angle selected depends on the goal of the tibial tubercle transfer (TTT). Steep angles are for degenerative disease of the patellofemoral (PF) joint and flatter angles are for cases of patellar maltracking.

Regardless of the angle for the tibial tubercle osteotomy, diagnostic arthroscopy is always the first step of the osteotomy (Figure 2), during which an assessment is made of the intra-articular structures. A patellar or trochlear chondroplasty is performed, if necessary.

A lateral retinacular release is rarely needed in cases of maltracking, but may be considered in patients with PF arthrosis in conjunction with maltracking. A lateral retinacular release is not done routinely and there are distinct complications associated with it. Further, lateral retinacular releases are contraindicated in patients with patellar instability.

Once the diagnostic arthroscopy and appropriate arthroscopic procedures are completed and the arthroscopic equipment is removed, the surgeon removes the knee holder side panels. The contralateral leg pillow is removed and a three-quarter-sheet is placed over the foot of the bed. The bed is slowly returned to a flattened position and both knees are extended on the bed.

The patellar tendon and tibial tubercle are exposed 4 cm to 5 cm (Figure 3). At this stage, the skin is relatively mobile, so it is possible to make a smaller incision. The anterolateral soft tissue is then elevated and retracted from the lateral tibia. Conventional or shaver drill bits are placed in the tibial tubercle at an angle that is dependent on if the underlying pathology is degenerative joint disease or patellar maltracking (Figure 4).

Tibial tubercle transfer
Figure 1. Before performing a tibial tubercle osteotomy, John P. Fulkerson, MD, suggests determining whether the goal is to correct an abnormal alignment vector.
Figure 2. Diagnostic arthroscopy is performed to assess the intra-articular structures and carry out any needed athroscopic procedures prior to TTT.
Figure 3. A 4-cm to 5-cm skin incision is made to expose the patellar tendon and tibial tubercle.
Figure 4. Conventional drill bits or shaver drill bits are placed in the tibial tubercle at the angle needed to address the PF pathology.
Figure 5. The osteotomy is performed with the saw blade anterior to the drill bits.
Figure 6. The osteotomy is continued behind the patellar tendon attachment so that it connects to the previous saw cut.
Figure 7. Anterior, medial or distal shift of the tubercle is done, as needed.
Figure 8. The shifted tubercle is held in place with a shaver drill bit so distal and proximal screws can be placed.
Figure 9. A washer is shown used on the proximal screw for better fixation and fragment compression.
Figure 10. The washer can be seen positioned lateral to the patellar tendon, but not contacting it.

Source: William R. Beach, MD

The osteotomy is performed with the saw blade anterior to the drill bits (Figure 5). The osteotomy must be completed behind the patellar tendon attachment, as well as down the lateral wall of the tibia so it connects to the previously completed saw cut (Figure 6).

The tubercle is shifted as needed (Figure 7). This can be done in a medial, anterior direction or distal direction if needed in patients with patella alta.

The tubercle is provisionally held with a shaver drill bit (Figure 8). The distal screw is placed in an inter-fragmentary fashion. The proximal screw is placed using the same technique described.

Then, a washer is used with the proximal screw to improve fixation and fragment compression (Figure 9). The washer rests just lateral to the patellar tendon, but does not contact the tendon (Figure 10).

The small incision and shorter osteotomy result in the ability to start early motion and weight-bearing. These result in an incision that is aesthetically pleasing compared with those used with other forms of this procedure; and patients are satisfied because their patellar position is improved or corrected.

Disclosure: Beach reports he receives IP royalties and research support from and is a paid consultant for Arthrex; he receives research support from DJ Orthopedics, ConMed Linvatec and Mitek; is on the editorial or governing board of Arthroscopy and Orthopedics Today, and is a board or committee member for the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America.

Tibial tubercle osteotomy, which was popularized by John P. Fulkerson, MD, when used for anterior medialization, has dramatically changed how patellofemoral pain is treated. The goal of tibial tubercle transfer is to improve patellar position so it reduces patella alta and/or lateral patellar tracking (Figure 1).

Tibial tubercle osteotomy can be carried out in various angles. The angle selected depends on the goal of the tibial tubercle transfer (TTT). Steep angles are for degenerative disease of the patellofemoral (PF) joint and flatter angles are for cases of patellar maltracking.

Regardless of the angle for the tibial tubercle osteotomy, diagnostic arthroscopy is always the first step of the osteotomy (Figure 2), during which an assessment is made of the intra-articular structures. A patellar or trochlear chondroplasty is performed, if necessary.

A lateral retinacular release is rarely needed in cases of maltracking, but may be considered in patients with PF arthrosis in conjunction with maltracking. A lateral retinacular release is not done routinely and there are distinct complications associated with it. Further, lateral retinacular releases are contraindicated in patients with patellar instability.

Once the diagnostic arthroscopy and appropriate arthroscopic procedures are completed and the arthroscopic equipment is removed, the surgeon removes the knee holder side panels. The contralateral leg pillow is removed and a three-quarter-sheet is placed over the foot of the bed. The bed is slowly returned to a flattened position and both knees are extended on the bed.

The patellar tendon and tibial tubercle are exposed 4 cm to 5 cm (Figure 3). At this stage, the skin is relatively mobile, so it is possible to make a smaller incision. The anterolateral soft tissue is then elevated and retracted from the lateral tibia. Conventional or shaver drill bits are placed in the tibial tubercle at an angle that is dependent on if the underlying pathology is degenerative joint disease or patellar maltracking (Figure 4).

Tibial tubercle transfer
Figure 1. Before performing a tibial tubercle osteotomy, John P. Fulkerson, MD, suggests determining whether the goal is to correct an abnormal alignment vector.
Figure 2. Diagnostic arthroscopy is performed to assess the intra-articular structures and carry out any needed athroscopic procedures prior to TTT.
Figure 3. A 4-cm to 5-cm skin incision is made to expose the patellar tendon and tibial tubercle.
Figure 4. Conventional drill bits or shaver drill bits are placed in the tibial tubercle at the angle needed to address the PF pathology.
Figure 5. The osteotomy is performed with the saw blade anterior to the drill bits.
Figure 6. The osteotomy is continued behind the patellar tendon attachment so that it connects to the previous saw cut.
Figure 7. Anterior, medial or distal shift of the tubercle is done, as needed.
Figure 8. The shifted tubercle is held in place with a shaver drill bit so distal and proximal screws can be placed.
Figure 9. A washer is shown used on the proximal screw for better fixation and fragment compression.
Figure 10. The washer can be seen positioned lateral to the patellar tendon, but not contacting it.

Source: William R. Beach, MD

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The osteotomy is performed with the saw blade anterior to the drill bits (Figure 5). The osteotomy must be completed behind the patellar tendon attachment, as well as down the lateral wall of the tibia so it connects to the previously completed saw cut (Figure 6).

The tubercle is shifted as needed (Figure 7). This can be done in a medial, anterior direction or distal direction if needed in patients with patella alta.

The tubercle is provisionally held with a shaver drill bit (Figure 8). The distal screw is placed in an inter-fragmentary fashion. The proximal screw is placed using the same technique described.

Then, a washer is used with the proximal screw to improve fixation and fragment compression (Figure 9). The washer rests just lateral to the patellar tendon, but does not contact the tendon (Figure 10).

The small incision and shorter osteotomy result in the ability to start early motion and weight-bearing. These result in an incision that is aesthetically pleasing compared with those used with other forms of this procedure; and patients are satisfied because their patellar position is improved or corrected.

Disclosure: Beach reports he receives IP royalties and research support from and is a paid consultant for Arthrex; he receives research support from DJ Orthopedics, ConMed Linvatec and Mitek; is on the editorial or governing board of Arthroscopy and Orthopedics Today, and is a board or committee member for the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America.