Background Information:

What are the other Names for the Procedure?

• Anteromedial Tibial Tubercle Transfer
• Elmslie-Trillat-Maquet Procedure
• TTT (Tibial Tuberosity Transfer)

Tibial Tuberosity Transfer (TTT) is also referred to by the type of techniques used; two most common techniques being Fulkerson and Maquet techniques. Both methods accomplish the same goal, with the main difference being in the angle of fracture.

What is Tibial Tuberosity Transfer surgical procedure?

• The Tibial Tuberosity Transfer procedure is termed as a controlled fracture in which, a small part of the shinbone, called the tibial tuberosity, is re-attached at a different location
• This allows the kneecap to move in a way that reduces stress and pressure applied on certain parts of the knee

What part of the Body does the Procedure involve?

The Tibial Tuberosity Transfer surgery involves a small section of the shinbone and parts of the knee joint.

Why is the Tibial Tuberosity Transfer surgical procedure Performed?

• A Tibial Tuberosity Transfer surgery is an elective surgery
• It is performed to improve the quality of life for patients with chronic knee pain that does not respond well to conservative measures

What are some Alternative Choices for the Procedure?

• Currently, there are no alternative choices for opting out of the procedure
• A Tibial Tuberosity Transfer is only considered when all conservative treatments, such as rest, ice, anti-inflammatory medication, and physical therapy, have been exhausted

What are the Recent Advances in the Procedure?

The most recent advancement to this procedure is the method by which the angle of fracture is adjusted.

What is the Cost of performing the Tibial Tuberosity Transfer surgical procedure?

The cost of Tibial Tuberosity Transfer procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Tibial Tuberosity Transfer procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.healio.com/Orthopedics/Knee/news/print/orthopedics-today/%7B5063B2D7-7C34-4092-9F3C-854D03D1BAAC%7D/Tibial-tubercle-transfer-surgery-offers-good-results-in-the-right-patients  (accessed on 08/03/2014)

http://bostonkneeandhipservice.org.uk/pdf/exercisefolder/PP_Tibial_Tuberosity_TransferDR.pdf  (accessed on 08/03/2014)

http://patellamd.com/16.html (accessed on 08/03/2014)

Prior to Tibial Tuberosity Transfer surgical procedure:

How is the Tibial Tuberosity Transfer surgical procedure Performed?

• The Tibial Tuberosity Transfer procedure is an open surgery that is performed, while the patient is under general anesthesia
• The patient may choose to receive a nerve block that will also help with pain management, during and after the procedure

Where is the Procedure Performed?

• The Tibial Tuberosity Transfer procedure is performed at a hospital
• The patient can choose to go home in the same day; but, staying overnight in the hospital is recommended for pain management

Who Performs the Procedure?

A trained orthopedic surgeon performs a Tibial Tuberosity Transfer surgery.

How long will the Procedure take?

It usually takes less than 60 minutes to complete the Tibial Tuberosity Transfer procedure.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Tibial Tuberosity Transfer procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines
• Generally, the patient will be given a list of instructions to be followed within 24 hours of the surgery. Some examples may include:
• No alcohol 24 hours, prior to procedure
• No food or drink after midnight (if surgery is to be performed the following day)
• Patients may also be asked to clean the knee that will be operated on, prior to surgery
• Patients are also expected to prepare their home in a way that reduces the incidence of trips or falls and makes regular needs more accessible (food, beverages, medications, entertainment, restroom, etc.)

What is the Consent Process before the Procedure?

A physician will request your consent for Tibial Tuberosity Transfer procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Tibial Tuberosity Transfer surgical procedure?

To assess the condition of the knee joint, some tests that may be performed include:

• X-rays of the knees
• CT scan to measure the TT-TG (distance between two important knee structures)
• MRI scan (to measure the length of the tendon in the front of your knee)

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is the Tibial Tuberosity Transfer procedure?
• Why is this procedure necessary? 
• What does the procedure involve?
• How will this procedure help?
• How long will recovery take? When can I resume normal work?
• How soon will I be allowed to bear weight?
• What is the success rate for patients like me?
• What will happen if I do not receive the procedure?
• How long, until I am able to return to work or school?
• Are there chances of a recurrence?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place while recovering?
• Is there any lifestyle restrictions needed after the procedure is performed?
• After recovering from the procedure, are there any follow ups or tests? If yes, how often?
• Is there any lifelong medication that needs to be taken after the procedure?
• How many procedure have you performed? 
• What is the cost of the surgery?

During the Tibial Tuberosity Transfer surgical procedure:

What kind of Anesthesia is given, during the Procedure?

A general anesthesia is administered during the Tibial Tuberosity Transfer procedure. Sometimes, the leg is numbed using a nerve block.

How much Blood will you lose, during the Procedure?

There is minimal blood loss involved during the Tibial Tuberosity Transfer procedure.

What are the possible Risks and Complications during Tibial Tuberosity Transfer surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Tibial Tuberosity Transfer surgery are:

• Overcorrection
• Nerve damage

What Post-Operative Care is needed at the Healthcare Facility after Tibial Tuberosity Transfer surgical procedure?

A patient, who chooses to stay overnight, may expect the following:

• Wound cleaning and dressing changes
• Powerful pain management
• Application of a locked brace
• Possibly some physical therapy
• Staying at the facility post-operatively is usually optional.

After the Tibial Tuberosity Transfer surgical procedure:

What are the possible Risks and Complications after Tibial Tuberosity Transfer surgical procedure?

Post Tibial Tuberosity Transfer procedure, the following complications may arise:

• Infection in the joint or at the site of the wound
• Delayed bone healing
• Development of scar tissue inside the joint
• Deep vein thrombosis
• Compartment syndrome

What is the Prognosis after the Surgery?

• If the Tibial Tuberosity Transfer surgery is successful, then the patient should be completely free of pain
• The patients should also be able to take part in light recreational activities
• Patients with minimal knee damage, prior to the surgery, may return to high-impact activities within one year

When do you need to call your Physician?

Do contact your physician, if you notice any of the following symptoms, after a Tibial Tuberosity Transfer surgical procedure:

• Any sign of infection, such as a fever over 101° F
• Pus and drainage at the incision site
• A sudden increase in pain
• Decreased ability of the patient to care for themselves
• No improvement of symptoms

What Post-Operative Care is needed at Home after Tibial Tuberosity Transfer surgical procedure?

At home, the following post-operative care is recommended, after a Tibial Tuberosity Transfer procedure:

• The patient must strictly adhere to the doctor’s advice upon arriving home. This usually consists of keeping the leg elevated, iced, and changing the wound dressing daily
• Patients must be very compliant with the physical therapy exercises prescribed
• It is recommended to have some help and support from a close relative or a friend, who can be around the house, for 1-2 weeks post operation

How long does it normally take to fully recover, from the Procedure?

A full recovery from a Tibial Tuberosity Transfer surgery, generally takes about 12 weeks.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Tibial Tuberosity Transfer surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital or outpatient facility
• The orthopedic surgeon
• Anesthesiologist

Individuals are advised to inquire and confirm the type of billing, before the Tibial Tuberosity Transfer surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA