Knee > Kneecap Dislocation > Treatments

    Tibial Tubercle Osteotomy and Distal Realignment

Treatment Introduction

In a tibial tubercle osteotomy with distal realignment procedure, the tibial tubercle, the prominent bony insertion of the patellar tendon into your shinbone (tibia), is partially or totally detached and moved and reattached in a better position that allows the kneecap to track better in its groove.

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in giving you the best possibility of a healthy recovery. Most insurance companies require a second opinion before agreeing to reimburse a patient for a surgical procedure. Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable in any case.

   Prior to your return home from the hospital, make sure you have received any equipment you will need when you get home from the hospital. This may include a knee brace, crutches, walker, ice packs or coolers, or a continuous passive motion (CPM) machine. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   Discontinue the use of any anti-inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, improve healing, and decrease complications, try to quit smoking or decrese the amount you smoke. In general, smokers have a higher overall infection and complication rate.

   If possible, practice walking with your crutches in case you need to use them after surgery.

   Make sure the orthopedist performing the surgery is board-certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

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Prior to surgery, you may be instructed to go to the hospital for pre-admission testing a few days before surgery. A nurse will review your medical history and provide you with all the preoperative instructions you need.You will be asked about your past medical history, given a complete physical exam and undergo the appropriate routine blood and urine tests and diagnostic studies (e.g. X-rays and electrocardiogram). If you are taking any medications, you will receive instructions about which medications to take and the appropriate dosing prior to your surgery. At most medical centers, you will go to "patient admissions" to check in for your surgery. There may be separate areas for ambulatory outpatients (patients who go home the same day after surgery) and for overnight inpatient surgery check-in. Be sure to ask your doctor or one of his assistants about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed and your knee area may be shaved (this is not always necessary). You will be asked to change into a hospital gown and, if necessary, to remove all of your jewelry, watches, dentures, and glasses. You will have the opportunity to speak with your orthopedic surgeon or one of his assistants, and meet the anesthesiologist or anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Unless requested, most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   If your surgery is going to be an outpatient procedure, arrange for someone to drive you home when you are released, as the anesthetic and pain medications may make you drowsy.

   If your surgery is going to be an inpatient overnight stay procedure, pack a bag for yourself that contains toiletries, underwear, personal phone numbers you may need, and any other items you would like to have during your hospital stay.

   Wear a loose pair of pants or other clothing that will fit comfortably over your knee bandage when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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A tibial tubercle osteotomy and distal realignment procedure usually takes one to one-and-a-half hours.

   General anesthesia is typically used for surgery, though in some cases a spinal or epidural anesthetic is used. You can expect to be given a sedative in the operating room before the anesthesiologist administers the anesthesia to put you to sleep.

   After anesthesia is administered, the surgical team sterilizes the leg with antibacterial solution and places clean drapes around the operative site.

   A four-to six-inch-long linear incision is usually made over or next to the prominent bony bump at the top of your shin (the tibial tubercle).

   A vibrating saw or an osteotome (a special bone chisel) is used to partially or totally detach the tibial tubercle while preserving the patellar tendon attachment to the bony tibial tubercle. The partially or totally detached tibial tubercle is moved and reattached in a better position that allows the kneecap to track better in its groove.

   In some cases, the tibial tubercle is slightly elevated in an attempt to decrease kneecap pain by decreasing the pressure on the undersurface of the kneecap. The tibial tubercle is usually reattached and fixed in place with metal screws.

   Occasionally, a lateral release is also performed to augment the tibial tubercle osteotomy with distal realignment procedure.

   The soft tissue structures previously cut are repaired in positions that will help the kneecap track mormally in its groove. These structures generally heal as strong as before the injury and surgery.

   The incision is closed, a sterile dressing is placed over the wound, and a knee immobilizer or cast is placed to restrict knee movement. You will then be taken to the recovery room.

   The screws remain in place unless they are irritating. This is not uncommon, especially in thin patients. If this is the case, the irritating screws will be removed after your tibial tubercle has fully healed in its new position.

After tibial tubercle osteotomy with distal realignment precedure, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of the anesthesia wear off. After surgery, you will experience some pain. Adequate pain medications will be prescribed for you. You will be given oral, IV (intravenous), or intramuscular pain medications when you ask for them. In some cases, you will be given an IV patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Your knee will be bandaged and may have ice on it. There will likely be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. You should try to move your hips, feet, and ankles while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the hospital or, if necessary, be admitted for an overnight stay. Depending on the type of procedure performed, the quality of your bone and fixation, and your surgeon's preference, you may or may not be allowed to bear any weight on your operative leg. Even if you are allowed to bear some weight on your operative leg, you will probably have to use crutches or a walker for a period of time. After surgery, your physician will give you specific instructions about how much weight you can bear on your operative leg. Occasionally, a tibial tubercle osteotomy with distal realignment precedure is an outpatient procedure. However, it is not uncommon for patients to spend one to two days in the hospital.

Because pain is relative and subjective, it is difficult to predict how much pain a given patient will feel after surgery. Staying overnight in the hospital allows your surgeon, anesthesiologist and nurses to carefully monitor your condition and control your pain. Some doctors may prescribe physical therapy after surgery to teach you how to walk and perform activities with the aid of crutches or a walker while following weight bearing restrictions. After surgery, you will experience some pain. Adequate pain medications will be prescribed for you. You will be given oral, IV (intravenous), or intramuscular pain medications when you ask for them. In some cases, you will be given an IV patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Be sure to ask for pain medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered safe. You will be given instructions about caring for your knee at home and schedule a follow-up appointment. You will also be given a prescription for oral pain medications. You will be unable to drive a car, so be sure to have arranged a ride home.

You will likely feel pain or discomfort for one to two weeks, and you will be given oral pain medications as needed. A prescription-strength pain medication is usually prescribed and should be taken as directed on the bottle. There may be some minor drainage on the dressing since fluid may have accumulated during the surgery. If you are not in a cast and are able to see your dressing, do not be alarmed to see some bloody drainage on your dressing over the first 24 hours. Here is what you can expect and how you can cope after a tibial tubercle osteotomy with distal realignment procedure:

   Your knee will be swollen for several weeks. The incision is usually from four to six inches long and takes a few months to heal completely.

   If external sutures or staples are in place, they should be removed approximately two to three weeks after surgery.

   You should usually continue with the ice for at least 24 to 72 hours, and if you are not in a cast, remove the dressing as instructed by your physician. Icing your knee as much as possible during the first two days after surgery will help reduce pain and swelling. Ice therapy is most effective in the first 24 to 48 hours.

   As much as possible, you should keep your knee elevated above heart level to reduce swelling and pain. It often helps to sleep with pillows or blankets under your ankle.

   Sponge bathe and keep your cast or knee immobilizer and wound dry. Do not shower or take a bath until your surgeon tells you it is safe to do so. Once you can, put your leg in a plastic bag and tie it around the top of your leg to keep your cast or knee immobilizer and wound dry.

   Crutches or a cane may be needed for four to six weeks following surgery.

   For two or three days after surgery, you may experience a low-grade fever of up to 101. Your physician may suggest acetaminophen, coughing, and deep breathing to get over this. This is common and should not alarm you.

   Depending on your pain threshold, you may be able to return to work in three to four days. If your job requires heavy lifting or other heavy activity, you may have to miss work for up to two months.

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Physicians usually suggest you rest your knee for four to six weeks while the kneecap's new attachment to the shinbone heals. You should not start aggressive rehab with weight-bearing exercising until instructed to do so by your surgeon. Your physician and physical therapist can help design a custom rehab program that is best for you. You will start slowly with range of motion exercises, and then proceed to strengthening exercises. Patients usually do stretching and strengthening exercises for a minimum of three days a week. The workouts should focus on the knee for at least thirty minutes and be combined with a knee-friendly cardiovascular workout. Physical therapy after a tibial tubercle osteotomy with distal realignment surgery follows a general pattern. Most people can begin stretching the muscles and tendons around the kneecap after about four weeks. Your knee is generally strong enough to handle mild stretching and slow movements. Working to restore early range of motion is important. It usually takes about six weeks for the shinbone to heal enough for you to begin more rigorous strengthening exercises. When stretching, try to avoid bending your knee past 90 degrees, which is roughly the knee angle when sitting in a chair with your feet flat on the floor. Rehabilitation progresses into strengthening exercises that focus on the quadriceps and hamstrings - the main stabilizing muscles for your knee. Physicians suggest you gradually increase the amount of weight as your leg muscles get stronger. Strengthening exercises require dedication because results often take months and pain may occur. Once the muscles of your injured leg are about as strong as the uninjured leg, the focus of rehab turns to increasing your coordination. After about eight to 12 weeks of rehab, physical therapy may become activity-oriented as you regain the ability to perform complicated movements, using stationary bikes, elliptical machines, and cross-country skiing machines. Coordination exercises continue for months until the kneecap is fully rehabilitated. It may take up to six months of rehabilitation to return to activities at full strength. Physicians usually suggest that you continue strength training even after your kneecap has been rehabilitated. Have your physician periodically check your kneecap for strength and proper tracking.

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Your main prevention goal following kneecap dislocation should be to strengthen your quadriceps and hamstring muscles so they are stronger than before the dislocation. You should try to feel comfortable that your leg muscles are powerful enough to snugly keep your kneecap in a normal alignment. Physicians usually suggest that you wear your knee sleeve during any activities that may stress your knee. The knee sleeve by itself may improve the tracking of your kneecap, however, to prevent kneecap dislocations, your rehab exercises are ultimately more important than bracing. Making the strengthening exercises you learned in rehab part of your regular conditioning routine is the best way to prevent future kneecap dislocations. Like any dislocated joint, once the first dislocation occurs, less force may provoke subsequent dislocations. You will have to rely much more on muscle strength to hold your kneecap in a normal position after a dislocation. Depending on the severity of your dislocation and the success of your rehab program, your physician may recommend that you avoid contact sports or risky, high-speed activities. In general, your kneecap can become healthy and stable after a dislocation, but you may need to be cautious of activities that could result in accidental collisions or falls. Besides the knee sleeve, consider wearing sturdy kneepads designed for crashes during activities like in-line skating and padded knee braces during contact sports. Your physician can recommend the best types of protective gear for your knees. You may know some people who seem able to pop their joint in and out of place painlessly. This should be avoided at all costs. The more your kneecap is popped out of place, the greater your chances of arthritis and the higher your risk of re-injury during activities.