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Distal realignment procedures

Distal realignment procedures, also known as TTT or tibial tubercle transfer procedures are performed to reposition the kneecap by realigning the tendon under the kneecap to. The tibial tubercle is the bony lump on the tibia (shin bone) below the knee cap. This serves as an attachment point for the patellar ligament/tendon. These procedures are done to prevent patellar subluxation or dislocation to prevent instability.

Distal realignment procedures include:

Maquet procedure – In this procedure, the tibial tubercle is cut, keeping the patellar tendon attachment intact. The tubercle is elevated by wedging the osteotomy of bone using a bone block. This procedure cannot move the tendon and tubercle medially (towards the inner aspect of the knee).

Elmslie-Trillat procedure – This is a procedure similar to Maquet procedure, but the tendon and tubercle can be moved medially.

Fulkerson procedure – In this procedure, the tibial tubercle is moved more towards the inner aspect of the knee. This is achieved by osteotomising the bone which allows the bone and the tendon to move more medially and forward (anteriorly). After the procedure, the bony osteotomy is held in place using screws.

Hauser procedure – In this procedure, the tibial tubercle is moved medially, but not moved forward (anterior). Because of the shape of the tibia, the tubercle may shift its position more posteriorly and the patella may be subject to increased pressure and therefore pain.

Roux-Goldthwait procedure – It is a distal realignment procedure where the patellar tendon is split vertically. The lateral half of the patellar tendon is pulled under the inner half (medial) and attached to tibia. This pulls the patella over to the centre and helps prevent excess lateral shift.

Anteromedial Distalisation – This is designed to move the patella attachment anteromedially (medially and forward) and distally to correct the height of the knee cap in patients with a long kneecap tendon. This method is very effective in resolving instability of the kneecap.

RCS Logo British Orthopaedic AssociationRoyal College of Surgeons of EdinburghOTSISBritish Association for knee surgeryISOAMDU LogoOTSIS