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Clinical Outcomes of Tibial Tubercle Transfer for Anterior Knee Pain and Patello-femoral Instability | OMICS International
ISSN: 2167-7921
Journal of Arthritis
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Clinical Outcomes of Tibial Tubercle Transfer for Anterior Knee Pain and Patello-femoral Instability

Paul YF Lee*, Syed Gul and Andrew Davies

Welshbone, South Wales Orthopaedics Research Network, Wales, UK

*Corresponding Author:
Paul YF Lee
Welshbone, South Wales Orthopaedics Research Network, Wales, UK
Tel: +447764614688
E-mail: [email protected]

Received date: May 11, 2016; Accepted date: June 11, 2016; Published date: June 17, 2016

Citation: Lee PYF, Gul S, Davies A (2016) Clinicial Outcomes of Tibial Tubercle Transfer for Anterior Knee Pain and Patello-femoral Instability. J Arthritis 5:204. doi:10.4172/2167-7921.1000204

Copyright: © 2016 Lee PYF, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Anterior knee pain and patellofemoral instability have a multi-factorial aetiology and are therefore difficult to treat. A variety of surgical treatment options have been proposed for such patients. Tibial tubercle transfer is one such option and has been described using different surgical techniques. There is however a paucity of literature regarding the procedure itself and its clinical outcomes. Purpose: This study describes the clinical efficacy and outcome of a Tibial Tubercle Transfer (TTT). Study Design: Case series. Methods: 86 consecutive patients who underwent TTT for anterior knee pain and/or patellofemoral instability were studied prospectively. All patients received the same rehabilitation protocol postoperatively. Clinical outcome was measured using the Kujala knee score pre-operatively and at follow-up. Patients were also asked to rate their satisfaction with the procedure. Mean duration of follow up was 1.7 years (6 months to 3 years). Results: 94% of patients were satisfied with their decision to undergo the operation at the latest follow up. The mean Kujala score pre-operatively was 46 points with a Standard deviation (SD) of 14.35. At 6 months the mean Kujala score had improved to 70 points with a standard deviation of 20.25. Patients with patella-femoral instability alone showed greater improvement of Kujala scores compared to patients with anterior knee pain alone or pain plus instability. Conclusion: Our experience suggests that tibial tubercle transfer provides a safe and effective surgical treatment option for patients with anterior knee pain and patellofemoral instability. Patients with patellofemoral instability preoperatively derived the most benefit.


Patellofemoral disorders; Anterior knee pain; Tibial tubercle transfer


Anterior knee pain and patello-femoral instability have a multi factorial aetiology and hence have a reputation for being difficult to treat [1]. Factors involved include soft tissue imbalance, bony abnormality and patellofemoralmalalignment or any combination of these [2]. Patellar tracking is complex and results from the interaction between soft tissues and bony structures. Patients with patellofemoral disorders commonly present with anterior knee pain, patellofemoral instability, crepitus and limping gait [2,3].Surgical management can be considered if symptoms persist despite optimal non-operative treatment [4,5]. Numerous operative procedures have been described to treat patellofemoral pathology. These include lateral retinacula release, reconstruction of vastusmedialis, medial patellofemoral ligament reconstruction, trochleoplasty and tibial tubercle transfer (TTT) but results vary [1,6-8]. There is no consensus on the indications for these various procedures. Recently literature reports suggest that TTT could be an effective treatment for anterior knee pain and address patella-femoral pathology [9,10]. The principle of TTT is to realign the extensor mechanism at the level of the tibial tubercle and hence offload the lateral patellar articular facet and centre the patella within the trochlear groove [11]. Different surgical techniques have been described in the literature for performing TTT and results vary considerably [12-17]. In our centre we have performed tibial tubercle transfer by a technique which involves medial rotation of the proximal tibial tubercle around an intact distal cortical bridge. This avoids concerns regarding the amount of bony tibial tubercle resection, degree of translation and subsequent bone healing. It also seeks to minimise the likelihood of post-operative avulsion of the tubercle. We report the clinical outcomes of a prospective series of 86 consecutive patients treated with this technique.

Materials and Method

Patients who present with symptoms of anterior knee pain, patellofemoral instability or both are assessed in a standardised fashion involving detailed history taking, clinical examination and investigations including minimally flexed skyline patello-femoral X rays and MRI scanning with axial slices. If the symptoms, signs and radiological investigations indicate that a trochlear groove is present but that the patella is not centered correctly within it and this is likely the cause of their symptoms then patellar re-alignment is considered. All patients who underwent tibial tubercle transfer between May 2011 and Jan 2014 were included in the study. The surgical procedure was performed or directly supervised by the senior author scrubbed in all cases. All patients received standard specific rehabilitation protocol (Table 1) postoperatively. The average length of follow up was 81+/-9.5 weeks. Patients were evaluated using the Kujalapatello-femoral score questionnaire which is a reliable and a widely used measuring tool for patella-femoral disorders [18]. Patients were also questioned regarding their overall experience and satisfaction after undergoing the procedure. SPSS version 20 was used to analyse the data, descriptive statistic, 2 tail dependent t-test and chi square test were used. Multi-regression analysis was performed to identify stratified factors.

Post Op Rehabilitation:
First 2 weeks: Straight knee brace, Full weight bearing encouraged. Crutches for balance.
2 - 6 Weeks: Straight knee Brace for all weight bearing. Encouraged to remove brace when seated to perform SLR and knee curls.
6 weeks+: Knee brace off. Formal Quadriceps rehabilitation regimen.

Table 1: Post-operative rehabilitation plan.

Operative technique

Under general anaesthetic with the patient supine and a high thigh tourniquet inflated, an initial arthroscopic examination of the patellofemoral articular surface, alignment and tracking of the patella is performed (Figure1). If the articular surfaces are intact but the patella is mal-aligned whilst the knee is cycled through a range of movement, the decision is made to proceed. The arthroscope is withdrawn and the infero-lateral arthroscopy portal incision is extended distally over the tibial tubercle (Figure 2). The margins of the patella tendon are defined and the periosteum on either side of the tibial tubercle is incised longitudinally for 3 to 4cm to mark out the osteotomy.



Figure 1: Arthroscopic evaluation of patella instability.



Figure 2: Extension of lateral portal incision.

The osteotomy is then performed horizontally with a micro sagittal saw and particular care is taken to avoid recessing the tubercle. A small bridge of distal cortex is left intact (Figure 3). After completing the osteotomy, the tibial tubercle is swung medially on its distal osteo-periosteal hinge. The medial displacement of the proximal end of the tubercle is around 50% of its width (8 – 12mm) and depends on the patient’s anatomy and the size of the tubercle footprint. A temporary k-wire is used to hold the tubercle in the new position (Figure 4).


Figure 3: Tibial tubercle cut.



Figure 4: Rotational transfer of tibial tubercle.

Two cortical small fragment screws are lagged and countersunk securing the osteotomy. The K wire is then removed (Figure 5). Patella tracking is assessed at this stage and an extra articular lateral release is performed leaving the synovium intact if the lateral structures are tight and resisting the medial correction. A knee brace is applied in full extension after wound closure and is worn for all weight- bearing for 6 weeks. The patient is encouraged to be fully weight bearing as soon as possible post operatively.


Figure 5: Rotated tibial tubercle post fixation.

Quadriceps rehabilitation is commenced at 2 weeks post operatively under the supervision of the physiotherapy department (Table 1). Patients are encouraged to remove their brace whilst seated to perform static quads straight leg raise and seated knee curl exercises. All patients were reviewed for radiographic assessment at 2 weeks and 6 weeks. Clinical outcome was measured at 6 months post operatively using the Kujala score and patient satisfaction assessment.


The mean age of the 86 patient included in the study was 31 years (14-60), 38% (n=33) were male and 62% (n=53) were female. The mean Kujala score pre- operatively was 46 points with a Standard deviation (SD) of 14.35. 14% (n=12) presented with anterior knee pain in isolation. 10% (n=8) presented with instability only and 76% (n=66) reported both instability and anterior knee pain. Mean operating tourniquet time was 28 minutes S.D +/- 5 min. Superficial wound infection was encountered in 3 patients post operatively, each was treated successfully with oral antibiotics. Six patients reported prominent metal work after the surgery and requested removal of the screws after a minimum of 6 months post-operative. One patient fell directly on to the knee whilst mobilising without their brace at 4 weeks post-operative contrary to their post-operative instructions. This
resulted in fixation failure at the osteotomy site. Revision fixation was required through the original incision. There were no thromboembolic or other complications. There were no fractures of the osteo-periosteal bridge at the distal end of the osteotomy.

At 6 months the mean Kujala score had improved to 70 points with a standard deviation of 20.25. At the latest follow up with a mean of 1.7 years, 94% of the patients were satisfied with their decision to undergo the operation. On further analysis of the sub categories within the Kujala score, the instability symptom was most improved, followed by pain and stair climbing ability post operatively.

Multi-regression analysis suggested that preoperative anterior knee pain, instability and previous dislocation did not influence patient satisfaction. Only female gender and older patient age had a statistical significant (p=0.0136) negative impact on the patient satisfaction. All 5 patients who were dissatisfied with the procedure were females.

The average pre-op Kujala score for females was 43.6 (S.D +/-15.2) compared to 50.9 (S.D+/- 13.8) for males. The average post-op Kujala score for females was 66.3 (S.D +/-22.7) compared to 75.3 (S.D +/- 18.58) for males (Table 2). Patients age 30 or younger (n=47) had significantly better outcome with only 2% having unsatisfactory results compared to 10% in the 31 years and above group (n=39). The average improvement of the Kujala Scores was 26 points in the under 30 group compare to 20 points improvement in the over 30 group. There were no cases of recurrent patella dislocation.

(n= 53)
Kujala Scores(Mean)
Preoperative 50.9 43.6
Postoperative 75.3 66.3*
Mean Improvement in scores: 24.4 22.7
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Review summary

  1. Carlo
    Posted on Aug 23 2016 at 11:36 am
    Authors have reported the clinical outcomes of patients treated with tibial tubercle transfer. It provided a safe and effective surgical treatment for patients. The document is a significant addition to the scientific literature in this field.

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