Abstract
Tibial tubercle osteotomies (TTOs) are a seemingly straightforward technique; however problems with bony union, implant failure, wound infections, and fractures have been reported in the literature. A database search identified all patients who had a TTO performed for patellofemoral instability between 1 March 2000 and 30 July 2008 by a single surgeon. The TTO technique was modified twice during the study period (December 2003 and June 2007, respectively), thereby creating three similar patient cohorts. TTOs were performed in 101 knees (90 patients), in which 34 knees (29 patients) received the blunt technique (TTO-B), 32 knees (30 patients) the sloped technique (TTO-S), and 35 knees (31 patients) the greenstick technique (TTO-G). Mean age of the patients (75 females, 15 males) was 16.0years (range 12.2-20.2years). Overall, six patients had complications, namely, six tibia fractures and no nonunions, for an overall complication rate of 5.9%. In the TTO-B group, four patients had four tibia fractures for an overall bony complication rate of 11.8%. In the TTO-S group, two patients had two delayed unions which developed into tibia fractures for an overall bony complication rate of 6.2%. There were no complications (0%) in the TTO-G group. No correlation was identified between TTO screw size and complications. The caudal aspect of the osteotomy was the location of the tibia fracture in five knees and the caudal screw in 1 knee, at a mean of 11weeks postoperatively. All fractures were treated only with splint or cast immobilization and protected weight-bearing. The overall bony complication rate was 5.9% for the TTOs in this study. Utilizing the TTO-G technique with rigid two-screw, bicortical fixation the complication rate could be lowered to 0%. Avoidance of periosteal stripping, and secondary cortical devascularization at the caudal aspect of the TTO appears to optimize bony consolidation, thereby minimizing fractures. Bony complications are an infrequent problem after TTO. Greensticking the distal end of the TTO can minimize postoperative tibia fractures. Running and sports should not be permitted until complete cortical healing is documented on the lateral radiograph.
Highlights
The treatment of patellofemoral pathology has been, and continues to be, challenging
At the time of tubercle osteotomies (TTOs), other concomitant techniques were performed in 90 knees
Diagnostic knee arthroscopy was performed in 81 knees (80.0%): in 26 knees of the TTO-B group (76.5%), 26 knees of the TTO-S group (81.2%), and 29 knees of the TTO-G group (82.9%) (Table 1)
Summary
The treatment of patellofemoral pathology has been, and continues to be, challenging. Nonsurgical management is typically the initial treatment, with surgical management indicated for specific pathologies (i.e., intra-articular loose bodies) and for selected patients whose nonsurgical treatment fails to adequately manage the patient’s symptoms. The distal procedure is designed to alter the force vector at the patellofemoral articulation by moving the medial patellar tendon (i.e., tibial tubercle osteotomy or Roux–Goldthwait procedure) or creating an additional medial ligamentous tether (i.e., semitendinosus and/or gracilis tendon transfer). The tibial tubercle osteotomy (TTO) is the workhorse technique for skeletally mature patients. This osteotomy can be performed in the coronal plane (i.e., Elmslie–Trillat procedure) or sagittal plane (i.e., Maquet-style anteriorizing osteotomy), or it can be biplanar (i.e., Fulkerson procedure), depending on the patient’s pathology and the surgical goals. A variety of TTO techniques (e.g., method of osteotomy creation, determination of osteotomy alignment, and osteotomy fixation) have been described with published ratings of excellent and good outcomes ranging from 66 to 96% [1, 4, 6,7,8,9,10,11,12]
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