Freely available online

 KNEE
The modified tibial tubercle osteotomy
for anterior knee pain due to
chondromalacia patellae in adults
A FIVE-YEAR PROSPECTIVE STUDY

C. M. Jack, Objectives
S. S. Rajaratnam, To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for
H. O. Khan, arthroscopically diagnosed chondromalacia patellae.
O. Keast-Butler,
P. A. Butler- Methods
Manuel, A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia,
F. W. Heatley who had failed conservative management, underwent a modified Fulkerson tibial tubercle
osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients
From Conquest exhibited signs of patellar maltracking or instability in association with their anterior knee
Hospital, St Leonards- pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)),
on-Sea, United with only one patient lost to follow-up.
Kingdom
Results
A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from
39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual
analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-
operatively. Overall patient satisfaction with good or excellent results was 72%. Patients
with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less
than younger ones. The outcome was independent of the grade of chondromalacia.
Six patients required screw removal. There were no major complications.

Conclusions
 C. M. Jack, BSc(Hons), MSc, We conclude that this modification of the Fulkerson procedure is a safe and useful operation
FRCS(Tr & Orth), Specialist
Registrar to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia
 H. O. Khan, MBBS, MRCS, patellae in adults, when conservative measures have failed.
Specialist Registrar
 O. Keast-Butler, FRCS(Orth), Keywords: Chondromalacia patellae, Tibial tubercle osteotomy, Anterior knee pain, Fulkerson, Modified
Consultant Surgeon
 P. A. Butler-Manuel,
FRCS(Orth), Consultant Surgeon Article focus Introduction
 F. W. Heatley, MB, FRCS,
Professor of Orthopaedics
 The treatment of recalcitrant anterior The term chondromalacia patellae was defined
(retired) knee pain with clinically normal tracking by Aleman in 1917.1 It means softening of the
Conquest Hospital, The Ridge, St
Leonards-on-Sea, East Sussex
by using the Heatley modified Fulkerson articular cartilage (Fig. 1) and is not synony-
TN37 7RD, UK. tibial tubercle anteriorisation mous with anterior knee pain for which there
 S. S. Rajaratnam, BSc(Hons), are numerous causes. It remains an enigma
FRCS(Tr & Orth), Consultant Key messages regarding both its pathology and symptoms.
Surgeon
Eastbourne District General  The Heatley modified Fulkerson Pain is often out of proportion with the
Hospital, Kings Drive, anteriorisation of the tibial tubercle has arthroscopic findings. Despite conservative
Eastbourne, East Sussex BN21
2UD, UK. good results with low complication rates management of this condition, up to 35% of
Correspondence should be sent
 It is a reliable procedure in the appropriate patients may require operative treatment.2
to Mr C. M. Jack; e-mail: patient with painful chondromalacia patellae The diagnosis of chondromalacia patellae
[email protected]
is generally based on arthroscopic findings.
Strengths and limitations Chondromalacia patellae is thought to occur
10.1302/2046-3758.18.2000083
$2.00
 This is a prospective study with only one as a result of abnormal stresses deep within
of 51 knees lost to follow-up at a mean of the arcades of Benninghoff3 secondary to
Bone Joint Res 2012;1:167–73.
Received 12 April 2012; Accepted
five years shear forces. Low impact stressing has been
after revision 30 May 2012  The cohort lacks a control group shown to cause vertical splitting of the

VOL. 1, No. 8, AUGUST 2012 167

168 C. M. JACK, S. S. RAJARATNAM, H. O. KHAN, O. KEAST-BUTLER, P. A. BUTLER-MANUEL, F. W. HEATLEY

Table I. The Outerbridge grading system for chondromalacia

patellae

Grade Description
Grade 0 Normal cartilage
Grade I Cartilage with softening and swelling
Grade II A partial-thickness defect with fissures
on the surface that do not reach
subchondral bone or exceed 1.5 cm
in diameter
Grade III Fissuring to the level of subchondral
bone in an area with a diameter more
than 1.5 cm
Grade IV Exposed subchondral bone

improve quadriceps function was first reported by

Maquet in 1963.6,7 Ferguson et al8 have reported up to an
80% decrease of the patellofemoral contact pressure after
an elevation of the tibial tubercle by 0.5 inches (1.27 cm).
Our study attempts to assess the effectiveness of tibial
Fig. 1 tubercle osteotomy as a treatment for arthroscopically
Electron microscope image of a section of human patella diagnosed chondromalacia patellae.
following freeze fracture processing, showing the struc-
ture of the articular cartilage.
Patients and Methods
All patients that presented to one consultant surgeon with
anterior knee pain between 1996 and 2001 were assessed
and treated according to a strict protocol. The patients who
were considered for inclusion in this study all complained of
persistent anterior knee pain that was interfering with daily
activities e.g. walking, running and climbing stairs. Those
patients with anterior knee pain in association with patella
maltracking, patellar instability or previous trauma to the
patella were excluded from this study. Patellar maltracking
was assessed clinically and radiologically. All patients pre-
operatively had skyline radiographs of the patella in 30°,
60° and 90° of knee flexion, along with weight-bearing
anteroposterior and lateral views of the knee.
All these patients were then enrolled in a physiotherapy
rehabilitation programme. Of these patients, those with
persistent unremitting anterior knee pain after a period of
six months were offered a diagnostic arthroscopy. At
arthroscopy, patients with chondromalacia patellae were
graded as per the Outerbridge system9 (Table I). Those
who received a therapeutic procedure such as a lateral
Fig. 2 release at the time of arthroscopy were excluded from
Electron microscope image showing fissuring in the radial inclusion in this study.
zone below an intact surface layer. The slits marked with * Those patients with chondromalacia patellae and per-
are the result of the freeze fracturing technique.
sistent anterior knee pain at six weeks after arthroscopy
were offered a Heatley modified Fulkerson10,11 tibial
tubercle osteotomy. They all provided informed consent
cartilage in animal experiments.4 Ohno et al5 have dem- for the procedure. In particular, the patients were coun-
onstrated a loss of proteoglycans near fissures within the selled about scarring (a midline longitudinal scar 7 cm to
matrix of the cartilage in chondromalacia. This leads to a 10 cm in length) and difficulty kneeling on their operated
loss of three-dimensional structure and the development knee post-operatively due to the anteriorised subcuta-
of matrix streaks and fissure formation (Fig. 2). neous position of the tibial tubercle. All patients were also
The idea of advancing the tibial tubercle anteriorly to informed that the subcutaneous screws might need to be
reduce the load across the patellofemoral joint and removed at a later date.

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 THE MODIFIED TIBIAL TUBERCLE OSTEOTOMY FOR ANTERIOR KNEE PAIN DUE TO CHONDROMALACIA PATELLAE IN ADULTS 169

A total of 47 patients (51 knees) thus received a tibial the distal end of the osteotomy. Elevation of this bridge
tubercle osteotomy between 1996 and 2001 and were facilitates positioning of the final drill holes on the medial
the subjects of this study. The tibial tubercle osteotomy and lateral sides allowing the osteotomy to be completed
was performed by one consultant surgeon (PABM) at a deep to this periosteal bridge (Figs 3a and 3b). The oste-
mean of 14 months (9 to 22) after their first presentation otomy is started proximally on the superior surface of the
in the outpatient clinic. Of the 51 knees studied, 15 had tibial tubercle. The osteotome is introduced relatively ver-
grade I, 17 had grade II, 16 had grade III and three had tically at the proximal end and relatively horizontally at
grade IV at arthroscopy. None had an Outerbridge grad- the distal end. The proximal medial limb of the osteotomy
ing of zero. should be at 20° to vertical, gradually flattening out until
The patients were followed-up post-operatively at two the most distal part of the osteotomy where the osteo-
weeks, six weeks, three months, six months, one year and tome is almost horizontal (Fig. 3c). The osteotomy is com-
annually thereafter. The final review was performed by pleted deep to the anterior periosteal bridge. Once the
one of three independent assessors (including one osteotomy has been completed the isolated tibial tuber-
author, CMJ), who had not been involved in the patient’s cle is freely mobile, attached proximally by the patellar
operation, in a dedicated research clinic. One patient was tendon and distally by the anterior periosteal bridge.
lost to follow-up at one year and was not included in the Because the proximal part of the osteotomy is very steep,
study. He was happy with his surgery at last follow up. a relatively large amount of anteriorisation is achieved
Therefore, 46 patients (50 knees) were followed for a with minimal medialisation. Typically the tibial tubercle is
mean of 72.4 months (62 to 118). There were seven male anteriorised by approximately 1 cm to 1.5 cm (Fig. 3d).
and 39 female patients with a mean age at the time of sur- The osteotomy is held in position with a 2 mm Kirschner
gery of 34.4 years (19.6 to 52.2). wire passed through the posterior tibial cortex. The oste-
Surgical technique. The Heatley modified Fulkerson otomy is fixed using two 3.5 mm self-tapping cortical
technique was used.10,11 The Fulkerson procedure, which screws also passed through the posterior tibial cortex by
was first described using medialisation and anteriorisa- hand to avoid possible damage to the posterior struc-
tion of the tibial tubercle without using bone graft. This tures. The wound is closed in layers.
was a smaller osteotomy than the Macquet. Heatley mod- The mean length of stay was 3.2 days (1 to 7). Patients
ified the angle of the osteotomy to achieve anteriorisation were allowed to fully weight bear post-operatively and
with minimal medialisation of the tibial tubercle. were immobilised with a cricket pad splint for a period of
This previously unreported technique involves a 7 cm two to four weeks. Normal activity was resumed between
to 10 cm vertical midline incision from the inferior pole of six and 12 weeks. The mean time off work was three
the patella to the distal end of the tibial tubercle. The months and mean time off sport 5.3 months.
patellar tendon is isolated by sharp dissection along its Objective evaluation was undertaken using the
medial and lateral borders. A curved artery forcep is Kujala functional knee scoring system.12 It is used to
passed from medial to lateral deep to the tendon as it assess gait, ambulation, support, stair climbing, insta-
inserts on the tibial tubercle. The jaws of the forceps are bility, pain, swelling, squatting flexion deficiency and
opened to allow enough space for a small Langenbeck thigh atrophy. A functional score between 0 and 100 is
retractor to be passed deep to the tendon from both the obtained. The closer the score is to 100, the better the
medial and lateral aspects. This allows enough retraction function of the knee.
of the patellar tendon to visualise the superior aspect of Patients were also assessed using a visual analogue
the tibial tubercle where the superior part of the oste- scale (VAS) for pain from 0 to 10, with 0 equating to no
otomy has to be made. pain and 10 the worst pain imaginable. In addition to this,
The medial and lateral limbs of the osteotomy are iden- a patient satisfaction score was used: 1) excellent or
tified by incising the periosteum on the medial and lateral much better than before surgery; 2) good or better than
borders of the tibial tubercle. It is helpful to partially before surgery; 3) fair or the same as before surgery; or
release the origin of tibialis anterior to enable good visu- 4) poor or worse than before surgery). The patients were
alisation of the lateral aspect of the tibial tubercle. A series also asked whether with hindsight they would have the
of 2.5 mm drill holes is now made along the medial and procedure again.
lateral limbs of the osteotomy and also on the superior Assessment of union of the osteotomy. Anteroposterior
aspect of the tibial tubercle which requires retraction of and lateral radiographs were used to assess radiological
the patellar tendon insertion first medially, then laterally consolidation of the osteotomy. The patients were also
using a Langenbeck retractor as described above. The clinically assessed for tenderness and mobility at the
osteotomy is then completed by connecting the drill osteotomy site at every post-operative visit. When all
holes with an osteotome. Care is taken to preserve an radiolucencies at the osteotomy site had filled in on serial
anterior periosteal bridge at the distal extent of the oste- radiographs, and the osteotomy was both non-tender
otomy. This is performed by passing a small periosteal and immobile, union was deemed to have occurred.
elevator under the periosteum from medial to lateral at Figure 4 shows a typical post-operative radiograph.

VOL. 1, No. 8, AUGUST 2012

170 C. M. JACK, S. S. RAJARATNAM, H. O. KHAN, O. KEAST-BUTLER, P. A. BUTLER-MANUEL, F. W. HEATLEY

Fig. 3a Fig. 3b

Fig. 3c Fig. 3d

Figures 3a and 3b – intra-operative photographs of the modified tibial tubercle osteotomy: a) drill holes
are made on either side of the tibial tubercle and a periosteal bridge is maintained distally. The drill holes
are then joined with an osteotome angled to make the triangular osteotomy which is more acute proxi-
mally than distally to improve the stability of the construct. b) The osteotomy is anteriorised and held in
place with two Kirschner wires before being held definitively with two 3.5 mm self-tapping cortical
screws to allow compression. Figures 3c and 3d – diagrams representing the position of the osteotomy,
showing c) that the angle of the cut is more acute proximally than distally, and showing d) the position
in which the osteotomy is fixed, with the acute angle of the medial limb of the osteotomy meaning that
little medialisation occurs for the degree of anteriorisation.

Statistical analysis. This was performed using SPSS soft- the 50 knees, 46 (92%) showed an improvement in their
ware (SPSS Inc., Chicago, Illinois). A Wilcoxon rank-sum Kujala scores post-operatively.
test was used to detect difference between pre- and post- The mean pre-operative VAS for pain was 7.8 (4 to 10),
operative scores. A Mann-Whitney U test was used to which had decreased by at five years to 5.0 (0 to 10). Of the
detect any difference between results by gender, and the 50 knees, 37 (74%) had an improvement in the pain score
Kruskal-Wallis rank sum test was used to see if the grade at the latest follow-up. This was again statistically signifi-
of chondromalacia affected results. Kendall’s rank correla- cant using the Wilcoxon test (p < 0.001) (Table II, Fig. 6).
tion was used to assess the correlation between pre- Six knees did not change, and seven had a higher score,
operative Kujala score and change in Kujala score, and the with a mean increase of 1.3 points (1 to 4) on the VAS.
difference in Kujala score when considered against age. A There was an obvious preponderance of females (39;
p-value < 0.05 was considered significant. 43 knees) over males (7; 8 knees) in this study. No signif-
icant difference was seen on either the post-operative
Results Kujala scores or VAS for pain when the results of the
Clinical results. The mean preoperative Kujala score was females were compared with the male patients (p = 0.797
39.2 (12 to 63). At final follow up this score had improved and p = 0.639, respectively; Mann-Whitney test).
to 57.7 (16 to 89) (Table II, Fig. 5). There was a statistically The grade of chondromalacia patellae did not make a
significant difference between the values using the significant difference to the expected improvement
Wilcoxon test with continuity correction (p < 0.001). Of (p = 0.28, Kruskal-Wallis rank sum). Older patients

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 THE MODIFIED TIBIAL TUBERCLE OSTEOTOMY FOR ANTERIOR KNEE PAIN DUE TO CHONDROMALACIA PATELLAE IN ADULTS 171

Table II. Mean pre-operative and 5-year post-operative scores

Pre-operative
Score Pre-operative Post-operative p-value* Post-operative
14
Mean visual 7.8 (4 to 10) 5.0 (0 to 10) < 0.001

Number of patients
12
analogue scale
for pain (range) 10
Mean Kujala 39.2 (12 to 63) 57.7 (16 to 89) < 0.001 8
score (range) 6
* Wilcoxon rank sum test 4
2
0

0
20

80
30

70

90
60
50
40
10

10
to

to
to

to

to
to
to
to
to

to
11

71
21

61

81
51
41
31
0

91
Kujala score
Fig. 5

Bar chart showing the distribution of Kujala scores pre-operatively and at

five years post-operatively.

Pre-operative
Post-operative
16

Number of patients
14
12
10
8
6
4
Fig. 4 2
0
A sample radiograph taken one year post-operatively. 0 1 2 3 4 5 6 7 8 9 10
Pain VAS
Fig. 6

benefited less than younger patients (Kendall's rank Bar chart showing the distribution of the visual analogue scale (VAS)
for pain pre-operatively and at five years post-operatively.
correlation τ = 0.201, p = 0.04). Patients with the lowest
pre-operative scores had the biggest improvement in
Kujala score and therefore appeared to benefit most from
surgery (Kendall's rank correlation τ = 0.254, p = 0.01).
Patient satisfaction. In terms of patient satisfaction, appointment, all signs of the superficial infection had
eight knees (16%) were rated as excellent, 28 (56%) as disappeared.
good, nine (18%) as the same as before surgery and five Only six knees (12%) required removal of screws due to
(10%) as poor. Furthermore, the patients comprising the patient experiencing pain while kneeling. Pain was
43 of the knees (86%) stated that they would have the relieved in four (8%) but two (4%) continued to experi-
procedure again. Two patients (two knees) who reported ence pain when kneeling.
poor results at five years, stated that they would have the
operation again, as the result of surgery had been very Discussion
good for previous years and only recently become worse. Whilst conservative treatment such as physiotherapy can
All patients were satisfied with the post-operative cos- be helpful for patients with anterior knee pain,13,14 there
metic appearance of their knee after the osteotomy. remains a group of patients with persistent debilitating
A total of 49 knees (98%) achieved bony union at one symptoms.
year. In the remaining knee with delayed radiological evi- At arthroscopy, experience is required in assessing the
dence of union, the Kujala score was 79 and the patient degree of softening of the articular surface when the
reported an excellent result at one year. articular surface of the dome is intact. It is always good
Complications. There was one undisplaced fracture practice to compare the dome with the concave lateral
through the proximal screw hole following a fall. This facet.
went on to unite satisfactorily without the need for fur- Many different procedures have been described to sur-
ther surgery. One patient had a superficial infection and gically treat chondromalacia patellae, such as drilling,
was treated with antibiotics successfully for five days by shaving,15 lateral release,16 medial plication17 and patel-
the general practitioner. At the two-week post-operative lectomy.18 Interestingly, Hejgaard and Watt-Boolsen19

VOL. 1, No. 8, AUGUST 2012

172 C. M. JACK, S. S. RAJARATNAM, H. O. KHAN, O. KEAST-BUTLER, P. A. BUTLER-MANUEL, F. W. HEATLEY

have demonstrated an advantage in combining anterior this to assess union of the osteotomy in our patients. We
displacement of the tibial tubercle to shaving alone. however believe that the appearance of progressive con-
The patella engages in the trochlear groove in about solidation of the osteotomy site on plain radiographs,
30° to 90° of knee flexion, and we believe that surgical used in conjunction with careful clinical assessment to be
anteriorisation of the tibial tubercle will decrease patello- suitably accurate in assessing union of the Heatley modi-
femoral contact pressure in this functional range in par- fied Fulkerson osteotomy.
ticular. The modified Fulkerson procedure seems a logical Our patient selection was based on strict inclusion crite-
method of treating this condition, because it adopts the ria. Using the Heatley modified Fulkerson technique, we
Maquet principle to decrease stress through the patella, have shown a 92% improvement of their symptoms in the
and does not alter the articular structure of the knee. Kujala score and with 86% reporting that they would have
Previously described tibial tubercle osteotomies the procedure again. The complication rate of 4% (one
include the Hauser,20 Roux-Goldthwaite,21 Trillat22 and superficial infection and one un-displaced fracture, both
Bandi23 procedures. These operations were designed to with good functional improvement at one year) for this
provide medialisation. Since our patient group did not procedure is lower than reported by other similar cohorts.
have significant patellar mal-tracking it was not appropri- The Heatley modified Fulkerson tibial tubercle osteo-
ate to alter this by medialisation of the tibial tubercle. tomy is a safe and useful operation to treat anterior knee
Jenny et al24 reviewed 100 patients who underwent the pain in well aligned patellofemoral joints due to chondro-
Maquet procedure for grade IV chondromalacia patellae malacia patellae in adults when conservative measures
at a mean follow-up of four years. The pain score have failed.
improved significantly after the operation and remained
The authors would like to thank K. Miles and D. East at the Research Department of the Con-
unchanged with longer follow-up. The success rate was quest Hospital, as well as the East Sussex Healthcare Trust Library.
62%. The failure rate was about 30% and they reported a
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 C. M. Jack: Writing the paper, Data collection
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 H. O. Khan: Statistical analysis
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