Tibial tubercle osteotomy (TTO)

The tibial tubercle is the bony bump at the top of the shin bone where the patellar tendon attaches. In a tibial tubercle osteotomy (TTO), the surgeon carefully moves that bony attachment and fixes it in a new position so the bone can heal. Changing its position can shift how the kneecap tracks and how force is distributed across the joint.

TTO is used to address selected factors — such as the alignment of the extensor mechanism, how the kneecap tracks, the height of the kneecap, or how load is shared across the cartilage. It is one option for particular knees, and not every patient with patellar instability requires it.

Whether a TTO is discussed depends on the individual knee. When the evaluation shows that alignment or other bony factors are contributing to instability or to how the kneecap loads the joint, a surgeon may consider repositioning the tubercle. The decision is individualized and is made together, based on your examination, imaging, and goals — not on instability alone.

It helps to distinguish TTO from the other procedures that may be part of patellar-instability surgery:

• Isolated MPFL reconstruction — rebuilding the soft-tissue restraint alone, without moving bone.
• Isolated TTO — repositioning the tibial tubercle alone to address alignment, tracking, patellar height, or cartilage loading.
• Combined MPFL reconstruction and TTO — addressing both the soft-tissue restraint and bony alignment together, when the knee needs both.
• Distalization or other TTO variations — specific adjustments to the realignment, such as moving the tubercle downward when the kneecap sits too high.
• Additional cartilage or ligament procedures — sometimes performed when there is cartilage damage or another injury inside the knee.

When a TTO is combined with MPFL reconstruction, the more protective set of restrictions governs and your surgeon selects the combined plan. Distalization or other TTO variations, cartilage restoration, meniscus repair, ligament reconstruction, revision surgery, or an additional osteotomy may call for different weight-bearing, motion, strengthening, and return-to-activity restrictions. In every case, the plan your surgeon selects and your operative note take precedence — no general protocol substitutes for them.

Recovery is staged, with progression of weight bearing, motion, and strengthening guided by osteotomy healing, symptoms, and the procedures performed. Recovery may take longer when other procedures are performed at the same time. Your surgeon and physical therapist give you the plan specific to you, and their instructions take precedence.

As with any surgery, a TTO has risks, which may include problems with bone healing at the osteotomy, hardware that can be prominent or need removal, fracture, stiffness, recurrent instability, persistent pain, blood clots, and infection. No operation guarantees that instability will never return. These trade-offs are discussed with your surgeon in the context of your own knee.