Tibial tubercle transfer surgery offers good results in the right patients

In an interview with Orthopedics Today's Chief Medical Editor, John P. Fulkerson, MD, offers his ‘pearls’ for optimal outcomes.

Issue: February 2004

Douglas W. Jackson, MD: When is a tibial tubercle osteotomy indicated in managing patellofemoral pain?

John P. Fulkerson, MD [photo] John P. Fulkerson, MD
Clinical Professor of Orthopedic Surgery and Sports Medicine Fellowship Director
University of Connecticut
Orthopedic Associates of Hartford, P.C.

John P. Fulkerson, MD: Tibial tubercle transfer is a definitive approach to aligning and/or unloading the patellofemoral joint. Unlike proximal realignment procedures, transfer of the tibial tubercle provides the option of anteriorizing and therefore unloading the patello-femoral joint.

I prefer a tibial tubercle transfer when there are symptomatic articular lesions on the patella that may be unloaded by transfer of the tibial tubercle. Consequently, I often add an anterior vector to the transfer by creating an oblique osteotomy.

Frankly, for patients with instability and minimal or no articular damage, I prefer an arthroscopic proximal re-alignment. In this way, I can monitor the position and tracking of the patella with the arthroscope.

Nonetheless, many patients, particularly active patients in mid-life, have lateral facet or distal central chondromalacia. In particular, this distal lesion will benefit from an anteriorizing vector at the time of realignment. A corollary is that some of these patients will actually get worse with medial imbrication, if there is articular loss distally and medially.

Arthroscopic proximal realignment is my procedure of choice for less severe malalignment when there is no concern about adding load to an articular lesion. I use an outside-in technique and no tourniquet.

COURTESY OF JOSEPH P. FULKERSON

Another group of patients who tend to benefit more from tibial tubercle transfer, as opposed to proximal realignment, are those with ligamentous laxity. Finally, for patients with extreme trochlear dysplasia, a medial patellofemoral ligament reconstruction or a trochlear osteotomy may be required in rare cases.

As a rule, an anteromedial tibial tubercle transfer is the best option when there is an excessive lateral pressure syndrome, lateral tightness, articular breakdown laterally and distally, or any concern about placing a load on an articular lesion by medial imbrication.

Jackson: What are the relative and absolute contraindications?

Fulkerson: Osteotomies are riskier in smokers and patients with poor bone quality. A patient must be compliant and willing to stay on crutches six to eight weeks.

One problem group in my practice has been obese females. These patients seem to fall down more frequently in the postoperative period, and I have now seen several avulsions of the tibial tuberosity or fractures of the tibia in obese females who lose their balance. I believe this is a relative contraindication to doing tibial tubercle transfer surgery.

Jackson: What technical “pearls” have you found critical in successful outcomes?

Fulkerson: Tibial tubercle transfer surgery, properly performed with early mobilization and secure fixation, is consistently successful when patients are carefully selected. Some of the pearls I have discovered are:

Perform absolute flat osteotomy tapered distally to within 1 mm of the anterior cortex at the distal extent of the osteotomy.
Complete an accurate transfer and secure fixation, usually with two 4.5 cortical screws into the posterior cortex.
Achieve range of motion within the first few days of surgery and progressing to 90º (this is one major advantage over proximal surgery).
Make the osteotomy from medial to lateral, reflecting the anterior tibialis muscle carefully and using direct vision of the exiting saw blade at all times.
Start the osteotomy cut distally so that the saw blade is easily visualized coming out the lateral side antero-distally, and particularly when doing an anteromedial tibial tubercle transfer, watch the saw blade exiting on the lateral tibia under direct vision.
Allow toe touch weight-bearing for six weeks and progress off crutches by eight weeks postoperatively when quadriceps support is confirmed.
Confirm a normal tracking pattern arthroscopically after the osteotomy is moved and before final fixation.
Do not overdo it.
Do not overdo the lateral release.
Leave the vastus lateralis intact.

Jackson: In the preoperative discussions, what sort of outcomes can the patient expect and in what time period?

Tips for tibial tubercle transfer surgery:

Perform absolute flat osteotomy tapered distally.
Complete an accurate transfer and secure fixation.
Achieve range of motion within the first few days of surgery and progressing to 90º.
Make the osteotomy from medial to lateral.
Start the osteotomy cut distally so that the saw blade is easily visualized coming out the lateral side antero-distally.
Allow toe touch weight-bearing for six weeks and progress off crutches by eight weeks.
Confirm a normal tracking pattern arthroscopically.
Do not overdo it.
Do not overdo the lateral release.
Leave the vastus lateralis intact.

Fulkerson: Accurate tibial tubercle transfer in young adult patients with healthy medial patella cartilage can yield satisfying results and return to sports. Patients who have more advanced articular cartilage loss and longstanding disability can still expect a significant step forward in their activity level but not necessarily progress to vigorous, full running sports.

Most patients after accurate tibial tubercle transfer surgery in the presence of isolated lateral articular erosion can expect to return to light recreational activities. The goals with tibial tubercle transfer surgery are to return patients to pain-free day-to-day existence with the ability to handle stairs without difficulty and to enjoy light recreational activities.