Tibial Tubercle Osteotomy

What is a tibial tubercle osteotomy?
An osteotomy is the movement of the insertion of the patella tendon by cutting through it and then re-securing it with two screws, in order for it to heal in this new location at the insertion of the patella tendon as it inserts into the top of the tibia (shin bone).  This procedure is done for several reasons.  One reason we perform this procedure is in patients who have instability of the patella (kneecap) to prevent it from dislocating.  The other reason this procedure is performed is to correct significant maltracking that may be leading to significant arthritic changes behind the kneecap.  By moving the bone, we can correct the malalignment of the kneecap in the groove of the femur (thigh bone) and eliminate symptoms of instability and decrease the symptoms of arthritis.  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 eliminate the symptoms of pain by reducing the forces on the kneecap. 

An arthroscopic procedure is performed with this procedure in order to inspect the inside of the joint.             

What is arthroscopy?
The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the knee joint through two small incisions.  A camera is attached to the arthroscope and the image is viewed on a TV monitor.  The arthroscope allows me to fully evaluate the entire knee joint, including the knee (patella), the cartilage surfaces, the meniscus, the ligaments (ACL & PCL), and the joint lining.  Small instruments ranging from 3-5 millimeters in size are inserted through the incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue.  Before the development of arthroscopy, large incisions had to be made over the knee joint to treat or diagnose injuries.  Today’s arthroscopic techniques allow more complete evaluations of the knee joint while accelerating the rehabilitation process. 

What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks.  Possible complications include stiffness of the knee after surgery or continued pain.  The use of arthroscopic techniques attempts to limit these complications.  Other complications include infection, bleeding, nerve damage, blood clots, or problems with the anesthesia.  Although I have never seen it in my patients, there is a chance that the osteotomy will not heal.  Certainly it is also possible that if a trauma or other unplanned event would happen after surgery, or if the restrictions are not followed closely, the osteotomy could be pulled away from the bone. 

What kind of anesthesia is used?
Knee arthroscopy can be performed with general anesthesia (going to sleep), or regional anesthesia (spinal or epidural block).  The type of anesthesia will depend on your choice.  The anesthesiologist will discuss your options the morning of surgery.  The anesthesiologist will also talk to you about getting a femoral nerve block.  This is a very useful procedure to minimize pain for the first eighteen to thirty-six hours and I would strongly recommend that patients undergo this procedure.

What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary.  If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray.  You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance.  The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery.  You may not eat or drink anything after midnight before your surgery.

How long will I be in the hospital?
Knee arthroscopy is an outpatient procedure you will go home the same day.

What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital or surgery center.  You will be admitted and taken to a pre-operative holding area where you are prepared for surgery.  You will be asked several times which extremity I am operating on.  Please note that you are asked this question many times on purpose.

After the operation you will be taken to the recovery room to be monitored.  Once the effects on anesthesia have worn off and your pain is under good control, you will be given your post-operative instructions and prescription for pain medication and released.  Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day.  I would recommend that you and your family members bring along some reading material to make the process easier for all.

How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee.  In general you can expect the following:

You will be given a prescription for pain medication.

You may not shower until you see me back on the third postoperative day. 

You will be instructed how to use crutches before the surgery.  You should bring a set of crutches with you to the surgery.  How long you use crutches will depend on the type of surgery performed.  Crutches are commonly used for several weeks until you get your muscle control back and until we feel comfortable with you allowing to put weight on it.

A straight leg brace is placed on the day of surgery.  This brace will remain on your knee until we see each other back on the third post-operative day.  On that visit we will change your dressing and instruct you on how to start some early range of motion. 

Resume your regular diet as soon as tolerated.  It is best to start with clear liquids before advancing to solid food. 

You should apply ice over the dressing for 20 -30 minutes every hour for several days.  Do not use heat for the first 48-72 hours.

Suture removal:
Some stitches are absorbable and do not need to be removed. However, if there are stitches they will be removed on your first post-op visit.

Return to work or school:
You can return to school or work anywhere from 2 days to 2 weeks.  If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.

What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports or work activity.  After lateral release, the rehabilitation generally occurs very rapidly.  We will instruct you on a home physical therapy program on your first post-operative visit on Day 3.  Simple exercises and range of motion will be given to you to perform on your own.  Formal physical therapy usually does not start until about three weeks post-op, due to the fact that there is not much for them to do in the early going.  After you start physical therapy, the emphasis will be on range of motion, improving your quadriceps muscle function, and restoring normal weightbearing and ambulation. 

When can I return to sports or full duty at work?
How quickly you return depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications; 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.  Obviously the type of work an individual does will determine how soon they go back to that type of activity.  As far as full sports activity, it usually will take approximately four months.