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Tibial Tubercle Transfer 27418

 

synonyms: anteromedial tibial tubercle transfer, AMZ, Tibial Tubercle Transfer, fulkerson, tibial tubercle osteotomy (TTO), tubercleplasty (eg, Maquet type procedure)

Tibial Tubercle Transfer CPT

Tibial Tubercle Transfer Anatomy

Tibial Tubercle Transfer Indications

  • Lateral patellar tilt / subluxation with Grade III or IV chondromalacia on the distal medial and/or lateral patellar facets.
  • Patellofemoral arthritis.
  • Failed lateral release.
  •  Tibial tubercle anteromedialization (Fulkerson osteotomy) is recommended for TT-TG (tibial tubercle (TT) to trochlear groove (TG) ) distances of more than 20 mm

Tibial Tubercle Transfer Contraindications

  • Normal patellar articular cartilage: in this case there is no need to anteriorize the tibial turbercle and a straight medial transfer (Tillat) is inidcated.
  • Absence of patellar malalignment
  • Diffuse patellar Grade III/IV Chondromalacia
  • Obesity
  • Smoker
  • Diabetic

Tibial Tubercle Transfer Alternatives

Tibial Tubercle Transfer Planning / Special Considerations

  • Councel patients on expected outcomes of improved symptoms, not completely normal knee.
  • Moving tibial tubercle anteriorly shifts the more proximal patellar articular cartilage into contact earlier in the flexion arc. This unloads distal patellar articular lesions.
  • Medialization decreases lateral and increases medial patellofemoral contact pressures
  • Lateral and distal lesions with lateral patellar tracking (most common)= anteromedial tibial tubercle transfer via and oblique osteotomy. (Tibial Tubercle Transfer JP, Am J Sports Med 1990;18:490)
  • Lateral lesion with lateral tracking = Trillat tibial tubercle transfer
  • Distal lesion with normal proximal cartilage (uncommon) = anterioriation of tubercle
  • consider concomitent autologous or allograft osteochondral core transfer especially if articular lesion is on trochlear side.

Tibial Tubercle Transfer Technique

  • Sign operative site.
  • Pre-operative antibiotics, +/- regional block.
  • General endotracheal anesthesia
  • Supine position. All bony prominences well padded.
  • Examination under anesthesia.
  • Tourniquet placed high on the thigh.
  • Prep and drape in standard sterile fashion.
  • Perform knee arthroscopy documenting condition of patellar cartilage and location of lesions. Patients should have near normal proximal medial facet cartilage for a successful anteromedial transfer. Perform chondroplasty as indicated.
  • Exsanguinant leg the Eschmar bandage. Inflate tourniquet.
  • Anterolateral longitudinal incision extending from the lateral patella to 5-6cm distal to the tibial tubercle.
  • Expose patellar tendon and lateral retinaculum.
  • Perform lateral release to the superior pole of the patella.
  • Expose tibial tubercle both medially and laterally by subperiosteal sharp dissection. Expose the distal patellar tendon medial and laterally.
  • Place custom anterior retractor on the proximal lateral tibia.
  • Place Mitek Tracker guide and pin in place with slope determined based on pre-operative plan. Osteotomy should taper anteriorly distally.
  • Begin osteotomy with multiple drill holes and saw.
  • Complete osteotomy with osteotome. Two cuts are needed proximally ensure tibial tubercle remains intact
  • Displace the tibial tubercle fragment anteromedially along the osteotomy plane. @15mm anteriorization.
  • Secure tibial tuberlce with bone clamp and place knee through ROM ensure central tracting in the trochlear groove.
  • Place two 4.5mm cortical lag screws for fixation. Proximal screw is placed 1-2cm distal to the patellar tendon insertion.
  • Assess patellar tracking.
  • Irrigate.
  • Close in layers.

Tibial Tubercle Transfer Complications

  • nonunion
  • tibia fracture (avoid creating stress-riser in tibia with osteotomy cut)
  • Compartment syndrome
  • Skin slough
  • Continued symptoms
  • Painful hardware: generally screws are removed at 8-12 months post-op.
  • Infection
  • DVT/PE
  • Neurovascular injury
  • Overcorrection . patellar instability
  • Undercorrection
  • Neuroma
  • Stiffness

Tibial Tubercle Transfer Follow-up care

  • Post-op: knee immobilizer or hinged brace locked in extention. Active and passive ROM exercises are start early 1-2 x per day. Toe-touch weight bearing.
  • 7-10 Days: wound check, Continue knee immobilizer, daily ROM exercises. 25% Weight-bearing with crutches.
  • 6 Weeks: Check xrays. wean out of immobilizer, Start active strengthening at 8 weeks. Gradually increase weight bearing to full-weight bearing provided xrays show evidence of union.
  • 3 Months:
  • 6 Months:
  • 1Yr:

Tibial Tubercle Transfer Outcomes

Tibial Tubercle Transfer Review References