Enumerate all Tibial tubercle osteotomies for patella instability with indications
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tibial tubercle osteotomy types indications patella instability Fulkerson Elmslie-Trillat Maquet
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Tibial Tubercle Osteotomies (TTO) for Patellar Instability
Tibial tubercle osteotomies correct patellofemoral malalignment by shifting the tibial tubercle in one or more planes (medial, anterior, distal, or combinations). The procedure is generally indicated in skeletally mature patients when TT-TG distance > 15-20 mm and/or Caton-Deschamps Index (CDI) > 1.2, usually after failure of conservative management or alongside MPFL reconstruction.
1. Elmslie-Trillat Procedure
Direction: Pure medialization (coronal plane only)
Mechanism: A flat osteotomy transfers the tubercle medially along the tibial surface, reducing the lateral force vector on the patella and correcting lateral tracking.
Indications:
- Recurrent lateral patellar instability with increased TT-TG (>15-20 mm)
- Lateral maltracking / chronic lateral subluxation
- Little or no articular cartilage damage (intact or near-intact chondral surfaces)
- Younger, active patients with good quadriceps strength
- Normal patellar height (no patella alta)
Note: Poor outcomes when degenerative changes or patellar chondromalacia are present - isolated medialization increases contact pressure on the medial facet and can worsen medial chondral disease.
2. Fulkerson Osteotomy (Anteromedialization - AMZ)
Direction: Oblique osteotomy - combined anteriorization + medialization (sagittal + coronal planes)
Mechanism: An oblique cut through the tibial cortex allows the tubercle to slide both anteriorly and medially. The angle of the cut can be varied (more oblique = more anteriorization; shallower = more medialization). Combines the Maquet concept with the Elmslie-Trillat concept.
Indications:
- Recurrent patellar instability with increased TT-TG AND articular cartilage lesions (especially lateral and distal patellar facet chondral wear)
- Patellofemoral pain failing nonoperative treatment with patellar maltracking or excessive tilt
- Isolated lateral/distal patellofemoral arthritis (younger patients)
- Chronic lateral subluxation with associated chondromalacia
- Most patients with malalignment - it is the most versatile and widely used TTO today
Key advantage: Can offload damaged lateral/distal chondral surfaces while simultaneously correcting alignment.
3. Maquet Osteotomy
Direction: Pure anteriorization (sagittal plane only)
Mechanism: The tubercle is elevated anteriorly (typically 2 cm), increasing the lever arm of the extensor mechanism and reducing patellofemoral joint contact forces. Also increases contact area, further distributing load.
Indications:
- Patellofemoral pain from mild/moderate patellofemoral arthritis (chondromalacia)
- Post-patellectomy pain
- No significant patellar malalignment (patellar malalignment is a contraindication to pure anteriorization alone)
Status: Largely fallen out of favor due to high complication rates - skin necrosis, wound breakdown, nonunion from large bone grafts needed. Modified/smaller anteriorizations have been adopted instead.
4. Hauser Procedure
Direction: Posteromedialization
Mechanism: Transfers the tubercle posteromedially. Historically used to correct patellar instability.
Indications (historical):
- Recurrent patellar dislocation (historical indication)
Status: Abandoned - posteromedialization significantly increases patellofemoral contact pressures, leading to accelerated patellofemoral arthrosis. Long-term results are poor. No longer recommended.
5. Roux-Goldthwait Procedure
Direction: Medialization (soft tissue + partial bony)
Mechanism: The lateral half of the patellar tendon is detached, rerouted medially beneath the medial half, and reattached to the tibia more medially. A partial or complete medial shift is achieved without full osteotomy in some versions.
Indications:
- Historically used for recurrent patellar dislocation, especially in younger/adolescent patients with open physes (to avoid damaging the physis with a formal osteotomy)
- Open growth plates where formal TTO is contraindicated
Status: Largely replaced by MPFL reconstruction in skeletally immature patients.
6. Distalization (Distal Transfer)
Direction: Distal shift (inferior)
Mechanism: Moves the tubercle distally, lowering the patella relative to the trochlea, improving patellar engagement with the trochlear groove at lower flexion angles.
Indications:
- Patella alta (CDI > 1.2 or Insall-Salvati ratio > 1.3) with recurrent patellar instability
- Instability attributed to patella alta where the patella "jumps" the trochlea before engaging it
- Often combined with medialization (AMZ + distalization) when both alta and lateralization are present
7. Anterolateralization (Reverse Fulkerson / Lateralization)
Direction: Combined anteriorization + lateralization
Mechanism: Moves the tubercle anteriorly and laterally to offload the medial patellar facet.
Indications:
- Isolated medial patellofemoral arthritis (medial facet chondral overload)
- Medial patellar facet lesions in patients with previously over-medialized tubercle (revision setting)
- Rare indication - primarily a revision procedure after overcorrection of prior medialization
Summary Table
| Procedure | Direction | Primary Indication |
|---|---|---|
| Elmslie-Trillat | Medialization | Instability, no/minimal chondral damage |
| Fulkerson (AMZ) | Anteromedial | Instability + lateral/distal chondral lesions (most common) |
| Maquet | Anteriorization | PF arthritis/pain, no malalignment (largely historical) |
| Hauser | Posteromedialization | Abandoned - causes arthrosis |
| Roux-Goldthwait | Medialization | Open physes, adolescent instability (largely historical) |
| Distalization | Distal shift | Patella alta with instability |
| Anterolateralization | Antero-lateral | Medial facet overload (revision) |
Key Decision Thresholds
- TT-TG > 15 mm: Consider TTO
- TT-TG > 20 mm: Strong indication for TTO
- CDI > 1.2: Consider distalization component
- Chondral damage present + malalignment: Fulkerson (AMZ) preferred over pure Elmslie-Trillat
- Normal TT-TG: TTO is generally not indicated; focus on MPFL reconstruction alone
Sources: Musculoskeletal Key - TTO surgical considerations | PMC - TTO review for patellar instability | PMC - TTO indications, outcomes, complications | Miller's Review of Orthopaedics 9th Ed | Campbell's Operative Orthopaedics 15th Ed 2026
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