Tibial tubercle osteotomy (TTO)
Tibial tubercle osteotomy (TTO) is a surgery used to treat kneecap dislocations or instability.
It changes the kneecap’s alignment in its groove so that it is less likely to dislocate. This involves moving a section of the bone which the patella tendon attaches to (the tibial tubercle) to a better biomechanical position.
Tibial tubercle osteotomy (TTO) is a surgery used to treat kneecap dislocations or instability. It changes the kneecap’s alignment in its groove so that it is less likely to dislocate. This involves moving a section of the bone which the patella tendon attaches to (the tibial tubercle) to a better biomechanical position.
It’s more commonly used for patients who have had long-term issues kneecap instability or maltracking that causes patellofemoral pain syndrome. This maltracking is often caused by the tubercle being too far from the outer part of the shinbone.
Other procedures are sometimes needed alongside TTO surgery. These include:
- MPFL reconstruction
- Knee arthroscopy
The most important preparation is to have a ‘settled’ knee with no effusion (extra fluid) and to get the quadriceps (thigh muscles) as strong as possible. The best results are achieved when working with a sports specialist physiotherapist who is in communication with your surgeon.
We run clinics to prepare people for this surgery - Click here
Before your surgery, the hospital will contact you to confirm the time you need to arrive and when you need to start fasting. If you are on a morning list, you need to stop all food from midnight and drink clear fluids only until 5:30 AM or two hours before the planned start, whichever comes first. For afternoon lists, that time is 11 AM.
Clear fluids include water, clear apple juice with no bits, or clear energy drink such as Gatorade. It does not include milk or cloudy juice with pulp.
You will arrive at the hospital between 1 and 2 hours before your surgery and will usually stay for 1-2 nights afterwards. One of our anaesthetists will give you a general anaesthetic, meaning you will be ‘asleep’ for the whole procedure. They may also put local anaesthetic around some of the nerves in your leg (nerve block) to reduce your pain after you wake up.
A tourniquet will be inflated around your upper thigh to reduce blood flow and allow a clear view inside the knee. Your surgeon will then make 2 to 3 small incisions (1cm) at the front of the knee and fill it with sterile saline (salty water).
The telescope (arthroscope) is then attached to a camera and inserted into the knee to look for damage and injured areas. These can be treated with a selection of small instruments.
The next step is preparing the tibial tubercle. This is done through a 10-15cm incision over the front of your shin bone, just below the knee joint. A 6cm section of bone with the patella tendon attached is moved towards the inner knee or further down the shinbone as needed, before being fixed back to the shinbone with screws.
At this point, extra procedures such as MPFL reconstruction can be performed if needed.
At the end of the procedure the incisions are injected with local anaesthetic, closed with dissolvable sutures, and then glued to provide a strong waterproof closure. A drain may be used overnight.
The surgery takes 1-2 hours on average with additional time before for anaesthetics and after for recovery. Relatives or partners will usually need to wait 3-4 hours between leaving the admissions area and getting back to the day stay ward.
Most patients experience some discomfort after waking up from a TTO surgery but it is generally well controlled with painkillers and the Game Ready machine.
You should experience little more than mild discomfort after waking up from an MPFL reconstruction. Recovery is usually fast and you will only need painkillers for a short period.
Length of stay
You will be discharged home 1-2 days after surgery when it’s safe and you are comfortable.
You will need crutches for the first 6 weeks after surgery (If you have your own, feel free to bring them). Following TTO surgery, patients are only allowed to put some of their weight through that leg and only when in the brace for the first 6 weeks.
Most patients can walk normally 7 days after surgery and can return to most activities in 6-8 weeks. Check with your surgeon before starting any impact activity such as running to avoid damaging the knee.
A brace is used to restrict bending for 6- 8 weeks total.
The bulky dressings can be removed the morning after surgery. You will have small, waterproof dressings underneath (insert picture) that you should leave on until your wound check at 10-14 days. It is common for some fluid to ooze out into the dressings over the first 24-48 hours and this can have a faint red colour to it. If it happens, the waterproof dressings may need changing.
You can shower with these dressings but avoid soaking in the bath, pool, or the ocean. If they come loose or get soaked, please replace them.
If you have been supplied with a Game Ready, please click here for information on how to set it up. We advise using it on program 2 or 3 and for up to two hours at a time. You can use it as often as you like in a day as long as you manage to complete your rehabilitation exercises. If your pain and swelling are well controlled, you don’t need to use it.
When supplied by Jointworks, you have the Game Ready for 2 weeks. At the end of this time it will be picked up by a courier unless you want to continue to rent it yourself.
Surgeon follow up
You will have your first post-operative visit with your surgeon at two weeks. This appointment is critical for checking your wound healing, assessing your knee’s stiffness, and answering any questions you may have.
Further follow up with your surgeon with x-rays at each visit until the bone has healed:
- 6 weeks after surgery
- 12 weeks after surgery
- 6 months after surgery
- 1 year after surgery and annually ongoing
After one year post-op you will discuss returning to higher levels of activity with your surgeon. After that, you will follow up with your surgeon on a yearly basis.
It is vital that you engage with a physiotherapist to maximize your early recovery from surgery.
At Jointworks, we recommend booking your first post-operative physio appointment as soon as we have a confirmed surgical date. This should be 2-5 days from the surgery. We will communicate the rehab plan with your treating physio, whether they’re one of our team or your own. They will help you manage swelling and stiffness before working on your leg strength and function. Finally, they will help improve your level of function for your chosen sport or activity and develop your program to reduce the risk of further injury.
- First 6 weeks – twice a week
- Second 6 weeks – once a week
- Ongoing – as directed by surgeon and physiotherapist
The TTO rehabilitation protocol we use is based on years of research and experience.
Click here for TTO rehabilitation protocols.
Return to driving
Returning to driving takes a minimum of six weeks for right knee surgery and two weeks for left knee surgery in an automatic car. You must be able to safely perform an “emergency stop” and you must have stopped all painkillers other than over-the-counter medications (such as Panadol or Nurofen). There is no specific documentation on this by licensing authorities, but checking with your car insurance company is recommended.
Return to work
After TTO surgery, the knee may remain swollen for up to 6 weeks. The incision sites are often puffy and firm for up to 3 months. Recovery to a point that the knee feels relatively normal for day-to-day activities can take 3-4 months.
The amount of time it takes to return to work depends on your level of activity. Most office workers can return to work after 2-4 weeks. Heavy manual workers may require 2-3 months before resuming full duties.
Return to sports
Low-impact activities such as walking, bike riding, swimming, and using an elliptical trainer can start around 3-4 months from surgery. Higher impact activities such as running and sports cannot be started safely until 8-12 months.
TTO surgery is a very safe procedure, but all joint surgeries carry some general risks.
The most common side effect is temporary pain and bruising. Other complications can include:
There may be a need for another operation if the bone fails to heal, the screws break, or if a large haematoma forms in the wound. The most common reason for reoperation is to remove screws that cause irritation after the bone has healed.
Blood clots in the leg
These are uncommon after TTO surgery but can cause severe swelling and pain. Clots that develop in the calf are called deep vein thrombosis (DVT) – these can travel to the lungs and cause a pulmonary embolism (PE). If a clot develops, you may need to take blood thinners for several months
This is very uncommon after TTO surgery (1%). If it’s just in the wound, antibiotic tablets or an IV drip may be needed. If the infection gets into the knee joint, further surgery be needed to wash the joint out.
There are very small nerve fibres in the skin around the knee that are always cut during the surgery. This leaves a small numb patch on the outer part of the leg past the scar. This numb patch tends to shrink over time and permanent nerve damage is rare, especially to the larger nerves that supply muscles.
Most patients are stiff following TTO surgery. This usually settles within the first few days to weeks. Even though modern techniques and early joint mobilisation prevents most stiffness, some patients suffer from excessive internal scarring called arthrofibrosis.
Delayed and non-union of the bone
The repositioned bone may take longer to heal than normal (35%). The risks for this are higher in smokers and diabetics. In about 2% of cases, it doesn’t heal at all and might need further operations.
Other uncommon complications include:
- Anaesthetic risks
- Allergic reaction to medications
- Heart damage
As always with the health system, the answer is ‘it depends.’
At Jointworks, our mission is to simplify healthcare through a better understanding of the system upfront. Therefore, while you can discuss the options specific to you with the team when you see your specialist -
If you are having surgery using your private health cover, the standard fees for the surgeon, anaesthetist, and assistant usually lead to a total out-of-pocket payment of around $3,500. This is the ‘gap’ that is left after Medicare and your insurance company have given you back their rebates.
Note that the anaesthetist is an independent practitioner and can charge a different gap which could affect this figure. We always provide you with their details and recommend you check their quote before committing to surgery.
The surgeons at Jointworks participate in the various reduced gap schemes run by different health insurance providers. However, please check for availability of surgical time slots first as there is often a wait of many months for this option.
Your insurance may also have an excess to pay, so please check. This is usually $500.
If you are having the operation through the public system, there is no out of pocket cost. Unfortunately, you are likely to have to wait up to a year for surgery.