Tibial Tubercle Osteotomy
Tibial Tubercle Osteotomy (TTO)
Tibial Tubercle Osteotomy (TTO) is a surgical procedure to improve alignment of the patella. This is performed by changing the insertion point of the patellar tendon on the tibia (tibial tubercle).
Who is a candidate for a Tibial Tubercle Osteotomy?
Tibial tubercle osteotomies are used to treat patients who suffer from patellofemoral instability (PFI) or painful patellar maltracking. By moving the bone (tibial tubercle), it can correct the malalignment of the patella in the groove (trochlea) of the femur (thigh bone) and eliminate symptoms of instability and decrease the symptoms of arthritis. Often patients who suffer from patellar maltracking have chronic anterior knee pain (see section on Patellofemoral Pain Syndrome). This is often manifested as pain with going up and down stairs and or sitting for prolonged periods of time. Tibial tubercle osteotomies are only effective in patients who do not yet have bone on bone osteoarthritis between their patella and femur (patellofemoral joint).
TTO can be performed in conjunction with Medial Patellofemoral Ligament Reconstruction (see MPFL Reconstruction) or cartilage repair surgery. Whereas the procedure is done to cure instability in patients who have an unstable kneecap, the procedure is performed to decrease symptoms of arthritis in patients who need this procedure. In other words, we cannot cure arthritis with a knee arthroscopy or with this procedure but can significantly decrease the symptoms of pain by reducing the forces on the patella.
How is the Surgery Performed?
You will be admitted to hospital on the day of your surgery. Your surgery will be performed using either a general anesthetic or a spinal anesthetic depending on your and your surgeon’s preference. The initial part of the procedure involves inserting a telescope into the knee joint (called an arthroscope) and inspecting the joint for any damage to the articular cartilage surfaces. At this stage, any cartilage injuries can be treated (see section on Cartilage Surgery).
An incision is then made on the front part of the knee. A 7cm long boney segment of the attachment of the patellar ligament (called the tibial tubercle) is repositioned and held in position with two screws, in order for it to heal in this new location. The TTO is performed to either move the attachment to the inner side (medial) and/or further down the tibia (distal).
What can you expect post-operatively after a Tibial Tubercle Osteotomy?
When you awake from surgery you will have a brace on your leg that will keep your leg straight.
It will be important for you to wear this brace at all times when you are up and about. You do not have to wear your brace to sleep.
You will also be given crutches and can only place a certain amount of body weight on you leg for the first 6 weeks.
This means that you will walk with two crutches at all times putting only the weight of your leg to the ground for balance.
Most people can go home after 1 to 2 days once your pain is well controlled. This time in the hospital also allows you to also meet with physiotherapy and get some early exercise and crutch training.
How will my pain be controlled after surgery?
At the time of surgery, local anaesthetic will be injected around the knee to decrease your pain. Often, the anaesthetist will inject an additional anaesthetic called a nerve block whilst you are asleep. This has a significant impact on reducing the amount of pain you experience. In addition, you will be given long-acting analgesic tablets to reduce your pain. You will be sent home from the hospital with a prescription for oral pain medication. The most commonly prescribed medications include anti-inflammatories (eg celebrex), regular panadol osteo and break through pain medication (eg endone).
Following week three you will begin to decrease your pain medication use to prior to physiotherapy and prior to bedtime. Most patients will not require any pain medication past 6 weeks.
When will I follow-up with my surgeon after surgery?
Your first post-operative visit will be with your surgeon at 2 weeks. This appointment is critical for checking your incision healing and range of motion as well as to answer any questions you may have. You will then follow- up with your surgeon 6 weeks after surgery, 12 weeks after surgery, 6 months after surgery, and one year after surgery. X-rays will be ordered at each visit up until the 3-month mark to ensure that the TTO is healing. At one year post-op you will discuss with your surgeon your return to higher level activity.
Frequently Asked Questions
Do the Screws Need to be removed in the future?
Some patients do find that they have some irritation from the retained hardware and in these cases both screws can be removed during a day surgical arthroscopy.
When will I start physiotherapy?
You will start physiotherapy beginning the day after surgery in the hospital and this will be continued once you are discharged. You will need to see your physiotherapist generally twice a week for the first 6 weeks, once a week for the next 6 weeks then reducing the visits from this time.
What will I do during physiotherapy?
The primary goal of physiotherapy is to initially increase ROM so that you do not get stiff following surgery. You will then begin to work on increasing strength and balance after surgery. You will be provided with a detailed protocol of what you should and should not be doing during each post-operative phase. You will provide this to your physiotherapist.
When do I need to wear my brace?
You will need to wear your brace anytime you are up moving around on your crutches. You will use your brace for 6-8 weeks on average.
How long will I need to use my crutches?
Depending on how quickly your bone heals and your surgeon’s preference you will need to use your crutches between 6 and 8 weeks on average.
When can I drive?
For patients undergoing right leg surgery, you may not return to driving until you have discontinued using your crutches (approximately 6 weeks). For patients undergoing left knee surgery that do not drive manual vehicles, you may return to driving between 3 and 6 weeks when you are no longer taking pain medication. You need to be confident that you can carry out an emergency stop and exit the vehicle unaided in the even t of an accident.
When can I shower?
You may shower following surgery with your knee brace off but you must be sitting down at all times. You will have water-proof bandages covering your incision. It is advisable to have some one help you get dry and dressed. The knee brace must then be re-applied.
When can I go back to work?
This will be different for each patient and depends largely on the type of work you do. Most patients who work in a sedentary position or desk work will be back to work by 4-6 weeks. Those patients who work in more labour intensive jobs may be out of work for up to 12 weeks.
When can I resume my regular activity?
Return to regular activity depends highly on each individual patient’s definition of regular activity. Non-impact activity such as walking, swimming, bike riding, and elliptical trainer can all be resumed by 3-4 months. Higher demand activity such as running and sports will not be able to be resumed until a minimum of 8-12 months.