I scrubbed on my first tibial tubercle transfer—a medializing Southwick dovetail osteotomy—in 1975 when an orthopedic surgery resident with our chairman Wayne Southwick, MD, at Yale University.
He inspired me. He was a creative man, a superb surgeon, and a noted sculptor.
Eight years later, in 1983 when I was an assistant professor of orthopedic surgery at University of Connecticut, I described anteromedial tibial tubercle transfer as a way to unload patella articular cartilage while aligning the extensor mechanism using a single oblique osteotomy. Since then, I have done close to 1,500 anteromedial tibial tubercle transfers — many on referred patients, some very complicated, some with difficult personalities and some who needed salvage from prior surgery referred by other physicians. I did them mostly for lateral tracking, unstable patellas and lateral patellofemoral arthritis.
I simply want to say tibial tubercle transfer works very well, is forgiving, and causes rare complications when properly done. Recently published studies have further confirmed the safety of anteromedial tibial tubercle transfer.
At a time when femoral derotation and trochleoplasty are more common than in years past, I simply want to say that tibial tubercle transfer, with or without distalization or anteriorization as needed, and properly done for the right indications, is remarkably effective, efficient and safe. It yields long-term joint preservation as well. I have referred 15-20 of the 1,500 patients with excessive femoral torsion for femoral derotation. I have referred less than 5 of the 1,500 patients for deepening trochleoplasty, but occasionally recess a supratrochlear spur without cutting under cartilage.
3D understanding of the patellofemoral joint makes decision-making for tibial tubercle transfer better now. One can appreciate trochlear contours, orientation, and curvatures well and thereby design an optimal tibial tubercle transfer, one that can help navigate a patella along a dysplastic trochlea. This can be done without the need for anything aside from added medial patellofemoral reconstruction and, sometimes, lateral lengthening. KISS principle applies – keep it simple and safe.
-Dr. John P. Fulkerson, MD