The document discusses the role of tibial tuberosity transfer in treating patellofemoral joint (PFJ) osteoarthritis (OA). It suggests that OA may sometimes be caused by abnormal joint geometry and mechanics rather than true OA. Tibial tuberosity transfer is presented as a way to improve PFJ mechanics and symptoms by changing its geometry. The procedure involves anteriorizing, medializing, or anteromedializing the tibial tuberosity to better align the patella. Care must be taken in patient selection and rehabilitation, and to avoid over-tightening soft tissues or using too large hardware. The goal is to optimize alignment and reduce pain without further damaging the joint.

1. Role of Tibial Tuberosity
Transfer in Treating PFJ OA
Vladimir Bobić, MD FRCS Ed
Chester Knee Clinic www.kneeclinic.info office@kneeclinic.info @ChesterKnee
www.slideshare.net/vbobic
Patellofemoral Masterclass 2018

2. Is This Doable? Does It Work?
• Is it possible to improve on patient’s “OA” symptoms by
changing the geometry and mechanics of the PFJ?
• What if OA is not OA? What if some OAs are just relatively
isolated accelerated wear and tear because of the joint
geometry, alignment, mechanics …?
• Or a consequence of a trauma, like the PTOA?
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3. PTOA
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4. Is This Doable? Does It Work?
• We have been driven by commercially successful concept
of “implantology” for many years but the time has come to
change gears and to try to use what Mother Nature gave
us.
• We can easily assume that our biological potentials are
much better than we think they are and that we simply do
not know how and when to use them well enough.
• To make “biology” work we have to understand, respect
and correct dynamic mechanics of the PFJ.
• Interesting Example: the anterolateral trochlea (the usual
OATS donor site) is often spared even in advanced OA and
seems to contain reasonably good bone marrow, which can
be aspirated through the donor site.
• The quantity and quality of good autologous bone marrow
is questionable, but as it seems that stem cells do not to do
the actual work (they seem to go around and boss other
cells and tell them where to go and what to do) so a few
mils of bone marrow aspirate may be good enough to kick-
start the process.
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5. Lateral Femoral Trochlea:
a reliable source of good cancellous bone and bone marrow, even in advanced OA
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MFC AVN

6. Where does the pain come from? “Perivascular and free nerve fibres have
been observed with the subchondral bone marrow and within the
marrow cavities of osteophytes.”

7. The Extent of Irreparable Chondral and Osteochondral Damage
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8. Subchondral Cysts = Terminal Metabolic Event
and Structural Failure!
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9. Mechanics, Geometry, Alignment … of course.
But, there are other fundamental issues:
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10. Does too much power (Quads/VMO exercises) cause more “OA”?
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11. Even lateral release works for some “OA” patients!
But, beware of numerous problems with this procedure (including
major haemarthrosis, even after careful electrothermal LR)
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12. CKC UK
Tibial Tuberosity Transfers

13. Anteriorization - the Maquet Technique

14. Medialization - Classic Roux-Elmslie-Trillat and Modifications
The procedure was originally described by Roux and later modified and
popularized by Elmslie and Trillat

17. Anteromedialization - the Fulkerson Technique

19. Anteromedialization - the Fulkerson Technique for PFJ OA

21. Take Home Messages:
• Anatomy!
• General Alignment and Q angle
• Meniscal deficiency?
• Ligament laxity?
• Bone quality?
• Trochlear dysplasia, chondral defects and osteophytes?
• Beware of over-medialization!
• Do not over-tighten medial soft tissues!
• Hardware issues (large washers, ...)
• Avoid “aggressive” rehabilitation
• Preop: Define goals, Discuss expectancies.
• Patient selection, Procedure information, Consent!
• And finally - avoid if there are any other options (like
doing nothing!)
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22. @BioKneeSociety
#bioknee2019

23. CKC UK
One More Take Home Message: