Results: Clinical Orthopaedics and Related Research
Functional Outcome After Tibial Tubercle Transfer for the Painful Patella Alta
ISSN: 0009-921XAccession: 00003086-200203000-00024Full Text (PDF) 1212 K
Author(s):
AL-Sayyad, Mohammed J. MD; Cameron, John C. MD
Issue:Volume 396, March 2002, pp 152-162
Publication Type:[SECTION II ORIGINAL ARTICLES: Knee]
Publisher:(C) 2002 Lippincott Williams & Wilkins, Inc.
Institution(s):From the Orthopaedic and Arthritic Institute, Sunnybrook and
Women's Health Science Center and the University of Toronto, Toronto, Ontario,
Canada.
Reprint requests to John C. Cameron, MD, Orthopaedic and Arthritic Institute, 43
Wellesley Street, East Toronto, Ontario, Canada M4Y 1H1.
Received: February 16, 2000.
Revised: September 25, 2000; February 5, 2001; June 1, 2001; August 10, 2001.
Accepted: August 30, 2001.
---------------------------------------------Outline
Abstract
MATERIALS AND METHODS
RESULTS
DISCUSSION
References
Graphics
Table 1
Fig 1
Fig 2
Fig 3
Table 2
Table 3
Table 4
Table 5
Table 6
Fig 4AB
Abstract
1
Twenty-five patients with painful patella alta without symptomatic subluxation
were identified in a prospective database. All patients had a distal tibial
tubercle transfer and preoperative knee arthroscopy. The mean postoperative
followup was 2.4 years. These patients were matched with healthy volunteers.
Patellofemoral scores using the scoring systems of Kujala et al and Lysholm and
Gillquist were collected prospectively. The Short Form-36 health survey and the
Western Ontario and McMaster Universities Osteoarthritis Index were used
postoperatively. Significant improvement in the patellofemoral scores was
documented postoperatively; however, the healthy volunteers had significantly
higher patellofemoral scores when compared with the patients who were treated
surgically. For the three Short Form-36 survey parameters based on physical
health (physical functioning, role physical, and bodily pain), there were no
statistically significant differences between the patients and the United States
age-matched norms; data are available in the Short Form-36 survey manual.
Patients with Grade 2 chondromalacia (fissuring and fragmentation less than 1.25
cm) had significantly better scores in pain and function domains of the Western
Ontario and McMaster Universities Osteoarthritis Index compared with patients
with Grade 3 (fissuring and fragmentation greater than 1.25 cm) and Grade 4
(erosion down to bone) changes. Distal tibial tubercle transfer is a beneficial
procedure for treating patients with painful patella alta.
---------------------------------------------The term patella alta was introduced by Schulthess 28 indicating that the
patella is located in an unusually high position. Patella alta is well
recognized as a predisposing factor for recurrent patellar dislocation.
1,9,13-15,21,25-27 In addition, patella alta is thought to be a potential cause
for other symptoms such as catching of the patella and recurrent effusions.
2,6,19,25,29 Ahlback and Mattison 2 reported that patella alta is approximately
six times as frequent in knees with patellofemoral arthritis, indicating that
patella alta is a pathogenic factor in patellofemoral osteoarthritis. Distal
tibial tubercle transfer has been successful in the treatment of patella alta
with recurrent patellar dislocation but was not explored as a treatment for
painful patella alta without dislocation. 29
To the best of the authors' knowledge, no study published in the English
literature explored the role of distal tibial tubercle transfer as a treatment
for painful nondislocating patella alta. The functional outcome after distal
tibial tubercle transfer is reported for patients who had anterior knee pain
related to patella alta without features of instability. Arthroscopic findings
and their role in formulating a treatment plan also are discussed.
MATERIALS AND METHODS
This is a clinical study of patients identified using the senior author's (JCC)
database. Patients were included in the study if they were seen between January
1994 and December 1998 and had a distal tibial tubercle transfer for painful
patella alta. Patients had to have preoperative arthroscopy providing a detailed
description of the articular surface in the different knee compartments. More
than 6 months nonoperative care had failed in these patients. Twenty-five
patients (29 knees) met the inclusion criteria for the study. All patients had
significant chronic anterior knee pain preoperatively, which was defined as
2
frequent pain with activities of daily living or constant pain with minimal
activities (Table 1). This anterior knee pain was characterized as being
retropatellar and worsened during activities such as going up and down stairs,
running, and jumping.
--------------------------------------------TABLE 1. Pain Scale
-------------------------------------------The average age of the patients was 35 years (range, 18-50 years) and there were
13 women and 12 men. One man and three women had bilateral patella alta. There
were 15 left knees and 14 right knees. No patients were receiving workers'
compensation. The followup ranged from 1 to 4 years with an average of 2.4
years. None of the patients had previous surgery. An age- and gender-matched
control group composed of 29 volunteers was established. The matching process
was done in a blinded fashion for functional outcome data. Preliminary screening
eliminated subjects with previous lower extremity injury or subjects who had
previous admissions or office visits because of lower extremity disease. The
Western Ontario and McMaster Universities Osteoarthritis questionnaire, 3,4 and
tests of Kujala et al 18 and Pidoriano et al 24 were administered to the
volunteers, the results of which were compared with the results of patients in
the postoperative group.
Preoperative evaluation included a detailed history (anterior knee pain,
patellar dislocation or subluxation, and history of trauma to the knee),
clinical examination (gait, limb alignment, knee effusion, knee range of motion
(ROM), Q angle, patellar tracking using the J sign, patellar tilt, apprehension
sign, and patellofemoral crepitus), and radiographic evaluation (anteroposterior
[AP] radiographs taken with the patient standing and lateral radiographs with
the knee in 30[degrees] flexion and a skyline view at 30[degrees] flexion). On
preoperative physical examination, all patients had prominent high-riding
patellas with a prominent inferior patellar fat pad and decrease in pain with
the knee flexed 25[degrees] to 30[degrees] or more. All patients had a normal
axis and Q angle; however, patients with patella alta can have a falsely normal
Q angle by virtue of the lateral displacement of the patella. 12 Also, no
patient had excessive external tibial torsion or internal femoral torsion. The
determination of patella alta was confirmed on radiographic examination (Fig 1)
and by the measurement as described by Insall et al. 15 Patella alta was defined
as an index of 1.2 or greater.
-------------------------------------------Fig 1. This lateral radiograph shows the knee of a patient with painful
patella alta.
---------------------------------------------Preoperative evaluation also included the modified Lysholm and Gillquist 20
score and the patellofemoral score of Kujala et al. 18 The Lysholm and Gillquist
score was adapted for patellofemoral pain and disability to give a functional
measure of normal knee activity. 11,20,24 A patient had an excellent result if
the modified Lysholm and Gillquist score was 95 to 100, a very good result if
the score was 90 to 94, a good result if the score was 80 to 89, a fair result
if the score was 70 to 79, and a poor result if the score was less than 70. The
questionnaire of Kujala et al is a patellofemoral rating scale with some
questions that specifically assess anterior knee pain symptoms, limp, support
3
used, walking tolerance, stair climbing, squatting ability, running, jumping,
prolonged sitting with the knee flexed, pain, swelling, abnormal painful knee
cap movements, thigh atrophy, and knee flexion deficiency with points given for
multiple choice answers. The maximal score is 100 and the higher the score the
better the knee status. 18 Both of these patellofemoral rating scales were used
knowing that pain is well expressed in the modified Lysholm and Gillquist scale
(representing 45 of 100 points compared with 10 of 100 points of the scale of
Kujala et al) which helped in the current study because much of the focus is on
pain in patella alta. 11,18,20
All arthroscopies were done by the senior author, using a superomedial inflow
cannula and standard anteromedial and anterolateral portals. A 30[degrees]
arthroscope was used. The depth and size of the articular cartilage lesions
identified during arthroscopy were classified using the Outerbridge system, 22
which includes the following stages for cartilage changes: Grade 1 chondromalacia,
change of color from glistening white to dull and yellowish white, abnormal
softening; Grade 2 chondromalacia, fissuring and fragmentation less than 1.25
cm; Grade 3 chondromalacia, fissuring and fragmentation greater than 1.25 cm;
and Grade 4 chondromalacia, erosion down to bone. All surgeries were done by the
senior author. The surgical technique was described previously. 29 A lateral
parapatellar incision was made. An osteotomy in the coronal plane of the
anterior 1 to 1.5 cm of the proximal tibia was made. The osteotomy was extended
5 to 6 cm below the tibial plateau and completed with a transverse cut at the
distal end. The free osteotomized fragment, which includes the patellar tendon
insertion, was transposed distally, bringing the patella down with it. Fixation
was secured with two 4.5-mm AO cortical screws in all patients. The tibial
tubercle was transferred distally by an average of 1.5 cm. A minimum of 1.3-cm
space was maintained between the inferior pole of the patella and the proximal
tibial articular surface in each patient to prevent iatrogenic patella baja.
Immediately postoperatively, all patients began ROM exercises from 0[degrees] to
30[degrees] and static quadriceps strengthening exercises. Active quadriceps
extension exercises were permitted after 6 weeks.
The postoperative followup included clinic visits at 1 month, 3 months, 6
months, and 1 year postoperatively, then annually thereafter. At the final
followup, the postoperative score of Kujala et al, 18 modified Lysholm and
Gillquist scale as described by Pidoriano et al, 24 Western Ontario and McMaster
Universities Osteoarthritis Index, 3,4 and Short Form-36 health status survey
31,32 outcome measures were used. Patients were asked to evaluate their
conditions compared with their preoperative status for pain, using the pain
scale shown in Table 1. 24 Also, patients answered a questionnaire postoperatively
which included questions regarding overall satisfaction with the procedure,
whether they would have the procedure again, and whether they participated in
sports postoperatively. All 25 patients participated in phone interviews for the
postoperative Western Ontario and McMaster Universities Osteoarthritis Index and
Short Form-36 health survey scores, and all patients returned for followup and
provided answers for the Kujala et al, Lysholm and Gillquist, and postoperative
questionnaires. The Western Ontario and McMaster Universities Osteoarthritis
Index is a tridimensional self-administered questionnaire probing relevant
clinically important outcome. 3 The Western Ontario and McMaster Universities
Osteoarthritis Index was presented in Likert form, 3 and included 25 questions
that were broken into three dimensions: pain (five questions) with possible
4
scores between 0 and 20, stiffness (two questions) with possible scores between
0 and 8, and physical function (17 questions) with possible scores between 0 and
68. Items were scored so that a lower score indicated a better health state. The
validity and reliability of the Western Ontario and McMaster Universities
Osteoarthritis questionnaire in measuring clinical outcome in patients with knee
arthritis has been reported previously. 4 The Medical Outcomes Study Short
Form-36 health survey has been described previously. 31,32 The instrument
includes a multiitem scale measuring health concepts including physical
function, role physical, bodily pain, general health perception, vitality or
energy, social functioning, role emotional, and mental health. These separate
scores can be analyzed individually. The scores of the health profiles are on a
scale of 0 to 100 with the higher score implying better health and less pain.
Postoperative followup included radiographic examination, which was evaluated to
determine the time needed for the osteotomy to heal (Fig 2).
---------------------------------------------Fig 2. This lateral radiograph shows the knee of a patient with painful
patella alta 4 weeks after distal tibial tubercle transfer with a healed
osteotomy site.
---------------------------------------------Statistical analysis was done using SPSS for Windows version 9.0 (SPSS, Cary,
NC). The Wilcoxon signed rank test was used to evaluate related Western Ontario
and McMaster Universities Osteoarthritis Index scores between patients and
control subjects. The Mann-Whitney U test was used to evaluate unrelated Western
Ontario and McMaster Universities Osteoarthritis Index scores between groups.
Paired t test analyses were used to evaluate the scores of Lysholm and Gillquist
20 and Kujala et al. 18 Short Form-36 health survey data were analyzed using
one-sample t test. The level of significance was p
RESULTS
Full ROM was attained by the time of followup in all patients, and quadriceps
weakness was overcome within 4 to 6 months after surgery. The postoperative
score of Kujala et al with a mean of 83 (range, 52-100) was improved significantly
compared with the preoperative score with a mean of 58 (range, 24-81) and p
value of 0.001. The control group had a significantly higher score with a mean
of 89 (range, 69-100) compared with the postoperative scores with a p value of
0.02. Also, evaluation of the postoperative Lysholm and Gillquist score showed
that 22 of the 25 patients achieved excellent or good results, one patient had a
fair result, and two patients had a poor result (Fig 3). The postoperative
Lysholm and Gillquist score with a mean of 88 (range, 43-100) was improved
significantly compared with the preoperative score with a mean of 58 (range,
47-78) and p value of 0.001. The control group had a significantly higher
Lysholm and Gillquist score with a mean of 94 (range, 65-100) compared with the
postoperative score (p = 0.04). For the subjective pain scale there was a
significant improvement in patient's pain postoperatively with a p value of
0.0001. According to the previously discussed pain score, 17 patients graded
their preoperative pain as fair and eight patients graded their pain as poor.
Postoperatively, eight patients had excellent pain relief, 14 patients had good
pain relief, and three patients had fair pain relief.
5
---------------------------------------------Fig 3. This bar graph shows the distribution of patients in the postoperative
group according to the modified Lysholm and Gillquist 20 scale.
---------------------------------------------In comparing the control group and the patients in the postoperative group, the
Western Ontario and McMaster Universities Osteoarthritis Index scores for pain,
stiffness, and function showed no significant differences between the two groups
(Table 2). Neither age or gender influenced the postoperative score of Kujala et
al, postoperative score of Lysholm and Gillquist, or Western Ontario and
McMaster Universities Osteoarthritis Index score to a significant degree. For
the three Short Form-36 health survey parameters based more on physical health
(physical functioning, role physical, and bodily pain), there was no statistically
significant difference when compared with United States age-matched subjects,
whose data are available in the survey manual. For the four (vitality, social
functioning, role emotional, and mental health) Short Form-36 health survey
domains that are based less on physical health, the current patients scored
significantly better than subjects in the control group with p values listed in
Table 3.
---------------------------------------------TABLE 2. Mean and Standard Deviation for the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC)3,4Scores of Control Subjects and
Patients in the Postoperative GroupSD = standard deviation; N/S = not statistically
significant
---------------------------------------------TABLE 3. Mean and Standard Deviation for Short Form-36 Health Survey
Scores of United States Age-Matched Control Subjects and Patients in the
Postoperative GroupPF = physical functioning; RP = role physical; BP = bodily
pain; GH = general health; V = vitality; SF = social functioning; RE = role
emotional; MH = mental health; SD = standard deviation; *statistically
significant (p
---------------------------------------------On arthroscopy, 19 knees had a normal appearing trochlea, but the remaining 10
knees had trochlear changes. Three knees had Grade 4 trochlear chondromalacia,
five knees had Grade 3 changes, and two knees had Grade 2 changes. Trochlear
changes were found in all patients in the lateral aspect of the trochlea. The
Lysholm and Gillquist score results for patients with trochlear chondromalacia
and patients with no trochlear changes are shown in Table 4. There was a trend
toward better scores (high postoperative score of Kujala et al, high postoperative
score of Lysholm and Gillquist, and lower scores in the three components of the
Western Ontario and McMaster Universities Osteoarthritis Index) in patients with
a normal trochlear groove compared with patients with trochlear chondromalacia,
but this was not statistically significant (Table 5).
---------------------------------------------6
TABLE 4. Patellofemoral Score of Lysholm and Gillquist20for Patients With
Normal Trochlea and Patients With Trochlear Chondromalacia
---------------------------------------------TABLE 5. Mean and Standard Deviation of Functional Outcome Scores in
Patients With Normal Trochlea and Patients With Trochlear ChondromalaciaWOMAC =
Western Ontario and McMaster Universities Osteoarthritis Index 3,4; N/S = not
statistically significant; SD = standard deviation
---------------------------------------------On the patellar side, 25 knees (86%) had involvement of the inferolateral part
of the lateral facet. Of the 25 knees, 13 patellas had Grade 2 changes, seven
patellas had Grade 3 changes, and five patellas had Grade 4 changes. Four
patellas had involvement of the medial facet, two patellas with Grade 2 changes
and two patellas with Grade 3 changes. Patients with mild patellar chondromalacia
(Grade 2, 15 knees) had a significantly better score in pain and function
domains of the Western Ontario and McMaster Universities Osteoarthritis Index
compared with patients with more severe patellar chondromalacia (Grade 3 and
Grade 4,14 knees) (Table 6). Using the Lysholm and Gillquist score for
postoperative assessment of patients with Grade 2 patellar chondromalacia there
were six excellent, three very good, and six good postoperative results. In
patients with Grade 3 patellar chondromalacia there were four excellent, four
good, and one poor result, and in patients with Grade 4 patellar chondromalacia
there was one excellent, two good, one fair, and one poor result. The Lysholm
and Gillquist score was significantly better in patients with a mild degree of
patellar chondromalacia compared with patients with more severe chondromalacia
(Table 6). The score of Kujala et al showed no statistically significant
difference between patients with mild chondromalacia of the patella and patients
with more severe involvement (Table 6).
---------------------------------------------TABLE 6. Mean and Standard Deviation of Functional Outcome Scores in
Patients With Grade 2 Patellar Chondromalacia and Patients With Grade 3 and
Grade 4 ChangesWOMAC = Western Ontario and McMaster Universities Osteoarthritis
Index 3,4, SD = standard deviation; *statistically significant (p
---------------------------------------------Considering patient satisfaction, 13 patients (52%) were very satisfied, nine
patients (36%) were somewhat satisfied, one patient (4%) was neutral, and two
patients (8%) were dissatisfied. Twenty-one patients (84%) stated that they
would have the procedure done again, two patients (8%) were not sure, and two
patients (8%) stated that they would not have the procedure done again.
All osteotomies except one were healed radiographically by the time of the first
followup (4 weeks). The average transfer distance was 15 mm (range, 10-20 mm).
Of the 29 surgeries, there were two significant complications (7%). There were
no cases of compartment syndrome, skin slough, neurovascular complications, deep
vein thrombosis, or arthrofibrosis. One patient had a nonunion of the osteotomy
7
site that was treated with open reduction, internal fixation, and bone grafting.
Another patient had a fracture of the tibial tubercle after a fall on the
anterior aspect of the knee 2 months postoperatively (Fig 4A) and was treated
with open reduction and internal fixation (Fig 4B). These two patients achieved
union and regained full ROM of the knee. Both patients were satisfied with the
index surgical procedure. Two patients required hardware removal (one was the
patient with the fractured tubercle) because of hardware pain.
---------------------------------------------Fig 4A-B. (A) A lateral radiograph of the knee of the patient who had a
fracture of the tibial tubercle after a fall is shown. (B) This lateral
radiograph shows the knee of the same patient after open reduction and internal
fixation of the fractured tibial tubercle.
---------------------------------------------DISCUSSION
Knee pain is a risk factor for disability in cross-sectional and longitudinal
studies. 8,16,17 Despite an abundance of clinical and basic science research,
patellofemoral pain is not completely understood. 1,5,6,10,11,22,23 In the
current study, a group of patients was identified who had significant anterior
knee pain related to patella alta (without clinical instability), which failed
to respond to nonoperative treatment and required distal tibial tubercle
transfer. Lancourt and Cristini 19 explored the relation between patella alta
and chondromalacia and concluded that there is a definite relationship, but no
treatment options were discussed. Caton et al 7 reviewed 50 patients with
patella alta to verify whether patella alta was a radiographic sign or was a
true anatomic and clinical entity. It was concluded that the existence of
patella alta, when responsible for a functional problem, must be considered and
treated to obtain a satisfactory result. Previous reports discussed the
correlation between patella alta and advanced patellofemoral arthritis but did
not recognize patella alta with absence of instability as a cause of anterior
knee pain. 2,6 Paar and Riederer 23 in a study of eight human knee specimens
simulated a high-standing patella that showed a considerable increase in the
femoropatella peak pressure to 90[degrees] flexion when compared with normal
knees. Their results showed that after simulated distal tubercle transfer there
was a decrease in peak pressure and an increase in the retropatellar contact
area. 23 Their study provided a legitimate reason for distal displacement of the
tibial tubercle in cases of the painful patella alta.
The functional outcome of patients who had distal tibial tubercle transfers for
painful patella alta has not been reported in the literature. The medical
outcomes study Short Form-36 health survey, 30-32 which is a reliable and valid
generic measure of functional status, well being, and general health perception
was used in the current study. Patients in the postoperative group compared
favorably with the United States control subjects in the physical domains of the
Short Form-36 health survey, and scored better in the mental domains which could
be related to the nature of referrals because the authors' institution is a
sports medicine oriented practice where patients tend to be well motivated. The
Western Ontario and McMaster Universities Osteoarthritis Index, which is a
tridimensional self-administered questionnaire probing relevant clinically
important outcomes also was used. 3,4 The Western Ontario and McMaster
Universities Osteoarthritis Index revealed that pain is expressed more in
8
patients in the postoperative group compared with control subjects but did not
reach statistical significance, possibly because patients in the postoperative
group may have residual functional impairment. There was no significant
difference in the remaining two domains (stiffness and function). The satisfaction
rate of tibial tubercle transfer in the current patients was 88%, which
indicates that the intervention was worthwhile to these patients. This
satisfaction rate is consistent with what was reported by Pidoriano et al 24
(83% satisfaction rate) in patients with lateral facet and distal patellar
chondromalacia who had an anteromedial tibial tubercle transfer.
In the current study, two patellofemoral scores (Kujala et al and modified
Lysholm and Gillquist) were used. 11,18,24 It has been argued that use of the
modified Lysholm and Gillquist score may overexpress pain, but pain interferes
with many of the specific tasks involved in other patellofemoral scales and
indirectly does have a high impact on patients. 18 With the current group of
patients having pain as a major feature of their disease process, it was
reasonable to use both scoring systems. Significant improvement in the modified
Lysholm and Gillquist score was observed, comparing preoperative and postoperative
results. The control group scored significantly better when compared with
patients in the postoperative group in both patellofemoral scores. No significant
difference was identified between the Kujala et al and Lysholm and Gillquist
patellofemoral scores. 18,20
The current report also describes the arthroscopic pattern of articular
cartilage damage in patients with painful patella alta. Pidoriano et al 24
discussed a group of patients who had anteromedial tibial tubercle transfer and
also had an arthroscopy. Locations of the patellar lesions were classified as
Type 1 (distal), Type 2 (lateral), Type 3 (medial), Type 4a (proximal), and Type
4b (diffuse). There was no description of patellar position on radiographs.
Pidoriano et al 24 concluded that the location of the lesion correlated better
with outcome after tibial tubercle transfer than the depth and extent of the
lesions as described by the Outerbridge classification. 22 The current study
showed involvement of the inferolateral region of the lateral facet of the
patella with possible involvement of the lateral aspect of the trochlea to be
classic findings of painful patella alta. These patellar changes were documented
in 86% of the patients. On the patellar side of the patellofemoral joint, mild
grades of chondromalacia correlated with a significantly better functional
outcome compared with more severe forms (Grades 3, 4) when the modified Lysholm
and Gillquist score and pain and function domains of the Western Ontario and
McMaster Universities Osteoarthritis Index score were used. A strong trend
toward significance also was seen using the score of Kujala et al. 18 There was
no significant difference in all functional outcome parameters used when
patients with trochlear involvement were compared with patients with a normal
trochlea. The lateral part of the trochlea was involved in all patients with
trochlear involvement. One possible explanation of the varying findings in the
current study compared with that of Pidoriano et al 24 is that in the current
study a subgroup of the population with anterior knee pain was studied. The
study of Pidoriano et al lacked plain radiographic descriptions.
In the current study distal tibial tubercle transfer had few complications. One
patient suffered a fracture after a fall and one patient who had a nonunion
achieved complete healing of the transfers after open reduction and internal
9
fixation with the addition of bone grafting in the patient who had the nonunion.
This did not negatively affect the patients' final functional outcome. The
current results compare favorably with the reported complication rate with
tibial tubercle transfer of various types. Simmons and Cameron 29 reported
(using the same surgical technique described here in patients with patella alta
and recurrent dislocation) that of 15 patients, one patient had deep venous
thrombosis and another patient had anterior patellofemoral pain develop.
Fulkerson et al 10,11 reported a complication rate of 25%. Of their 51 patients,
nine of the first 25 patients had stiffness develop requiring manipulation under
anesthesia, one patient had late tibial tubercle fracture, one patient had acute
avulsion of the tibial tubercle, two patients had deep vein thrombosis requiring
heparinization, and two patients had prolonged weakness requiring physical
therapy after surgery. 10,11 Fulkerson et al 10,11 stated that since starting
knee motion in the immediate postoperative period (after the first 25 patients),
stiffness had not been a problem. Bellemans et al 5 reported a complication rate
of 3.5% with the Fulkerson osteotomy (done for chronic anterior knee pain with
patellar subluxation). One patient had a tibial fracture at the distal end of
the osteotomy that was treated nonoperatively and healed uneventfully. 5
Routine arthroscopic examination is used before considering distal tibial
tubercle transfer as a treatment option for painful patella alta. Arthroscopy
provides information that helps in formulating a treatment plan. It provides
detailed information about associated joint disease and degree of articular
cartilage changes. From an arthroscopic examination one can determine if there
is healthy articular cartilage remaining on the more proximal articular surface
of the patella, so that after the distal tibial tubercle transfer, a healthy
articular surface will be articulating with the trochlea. Provided that there
are no central trochlear lesions (determined arthroscopically) such a transfer
should provide healthy articular surfaces on both sides of the patellofemoral
joint. Patients with more severely involved patellar articular cartilage do less
well when compared with patients with Grade 2 changes (fissuring and fragmentation
less than 1.25 cm). Pidoriano et al 24 showed that patients with central
trochlear lesions had poor outcome with anteromedial transfer of the tibial
tubercle and considered central trochlear lesion to be a contraindication for
such a transfer.
A limitation of the current study is that followup is short-term. Data for these
patients were collected during a 5-year period; however, the number of patients
reported is small. The study also lacks preoperative Short Form-36 health survey
and Western Ontario and McMaster Universities Osteoarthritis Index data, which
would have been helpful.
Distal tibial tubercle transfer is a beneficial procedure for treatment of
patients with painful patella alta. Significant postoperative improvement in
disease-specific functional outcome is documented. The typical location of
patellar lesion was the inferolateral region of the patella. Patients with less
severe patellar lesions had a better functional outcome.
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