Reviewed by Dr Vishal Pai
A tibial tubercle osteotomy (TTO) moves the bony bump at the top of your shin, where your kneecap tendon attaches, so that your kneecap sits and tracks better. This page covers who might need one, how it’s done, recovery, results and risks.
At a Glance
- A TTO moves the bony bump below your kneecap (the tibial tubercle, also called the tibial tuberosity) a short distance and fixes it with a plate and screws. This changes the direction your kneecap is pulled.
- It’s mainly used when your kneecap keeps dislocating because of the way the bones are lined up, for example when the tendon attaches too far to the outside or the kneecap sits too high. It’s usually done together with an MPFL reconstruction.
- Exercise strengthens the muscles around the kneecap but can’t change how the bones line up. A TTO can.
- You’ll use crutches for about 6 weeks while the bone heals.
- In studies, most people had less pain and a more stable kneecap afterwards, and the kneecap dislocating again was uncommon [1] [2].
What is a tibial tubercle osteotomy?
The tibial tubercle is the bump you can feel just below your kneecap, at the top of your shin bone. Your kneecap tendon joins the bottom of your kneecap to this bump. When your thigh muscle tightens, it pulls the kneecap along that line. If the bump sits too far to the outside, or too low down the shin, the kneecap is pulled off course.
In a TTO, the bump is cut free, moved a short distance and fixed with a plate and screws. The bone then heals in its new position. Depending on the problem, the bump is moved:
- Inwards (medialisation), when the tendon attaches too far to the outside
- Down the shin (distalisation), when the kneecap sits too high
- Inwards and forwards (anteromedialisation, also called a Fulkerson osteotomy).
Who might need a tibial tubercle osteotomy?
Physiotherapy builds up the muscles that control your kneecap, but it can’t move the bones. When your scans show the bump is out of position, a TTO corrects it. It’s usually combined with an MPFL reconstruction, which replaces the torn ligament on the inner side of your kneecap. The patella stabilisation surgery page explains how the different operations fit together.
When the tendon attaches too far to the outside
A CT or MRI scan measures how far the bump sits to the outside of the groove your kneecap runs in. This is called the TT–TG distance. The further out the bump sits, the harder the tendon pulls your kneecap outwards, and the more likely the kneecap is to dislocate again [3]. Moving the bump inwards can improve how the kneecap tracks [4]. Studies don’t fully agree on the exact measurement at which this helps [5], so Dr Vishal Pai looks at your scans together with how your kneecap moves when he examines you and what you want to get back to.
When your kneecap sits too high
When the kneecap sits too high (patella alta), it has less of the groove to hold it as you start to bend your knee. Moving the bump down the shin brings the kneecap back to a normal height [6].
What is involved in a tibial tubercle osteotomy?
The operation is done under a general anaesthetic. If an MPFL reconstruction is done at the same time, the steps for that are on the MPFL reconstruction page. The TTO steps are:
1. Checking the joint
The inside of the knee is usually checked first through two or three small cuts (arthroscopy), and any loose pieces of cartilage are treated.
2. The bone cut
A cut is made over the front of your upper shin. A surgical saw then cuts the tubercle free from the shin bone, along with the tendon attached to it.
3. Moving the tubercle
The tubercle is moved inwards, down the shin, or both. Dr Vishal Pai plans how far to move it from your scans before the operation.
4. Fixing it in place
The tubercle is held in its new position with a small, low-profile plate and screws while the bone heals.
How long does it take to recover from a tibial tubercle osteotomy?
Recovery is paced by bone healing, so it takes a little longer than after an MPFL reconstruction on its own. Your physiotherapist leads the rehabilitation, and you move to the next stage when your knee is ready rather than on a set date.
As a rough guide:
- Day after surgeryYou go home after an X-ray. You can put weight on your leg using crutches, and you wear a straight-knee brace when you walk.
- 2 weeksDr Vishal Pai checks your wound and the brace comes off. You can shower without a dressing once the wound has healed.
- 6 weeksMost people stop using crutches.
- 8 weeksAn X-ray checks that the bone is healing. Once it has, you can usually start driving again. By now your knee should straighten fully and bend past a right angle.
- 6 months or laterDr Vishal Pai reviews you to check the bone has healed. The earliest return to sport is at 6 months, once you’ve passed return-to-play testing.
Returning to work takes about twice as long as after an MPFL reconstruction on its own. Most people with a desk job go back after about 4–8 weeks, and physically demanding work can take up to about 12 weeks.
The earliest return to sport is at about 6 months [7]. It often takes longer than after an MPFL reconstruction on its own, and sometimes around a year when an MPFL reconstruction is done at the same time [8]. Swelling can take a few months to settle.
What results can you expect?
A TTO usually eases knee pain and improves how well the knee works [1]. When it’s done for a kneecap that keeps dislocating, the kneecap dislocating again is uncommon, at about 3 in 100 people in the first couple of years [2].
Most people get back to sport, and many return to the level they played at before [9] [8]. Results vary from person to person, and your own result may differ.
What are the risks and complications?
Every operation carries risks, and Dr Vishal Pai will go through them with you before you decide. Serious complications are uncommon [2]. Studies that also count removal of the plate and screws, and stiffness, report more problems [10]. The risks specific to a TTO are:
- Irritation from metalware. The plate and screws sit just under the skin at the front of the shin and can become irritating. Up to about 1 in 3 people have them taken out later in a second operation [1] [11] [12]. They are only removed if they cause symptoms.
- Slow bone healing. Occasionally the bone is slow to heal, or doesn’t heal (non-union) [13]. Smoking makes complications more likely [14].
- A break in the shin bone. This is rare [15]. It usually needs another operation to fix.
- Stiffness. Some knees become stiff [13] [16]. If your knee isn’t bending or straightening well by 6–8 weeks, a short anaesthetic to gently bend the knee may be needed.
- Numbness or altered feeling in the skin around the scar [16].
The general risks of knee surgery, such as infection, bleeding and blood clots, are covered on the patella stabilisation surgery page. You will also receive a written information sheet with the full list of risks.
Where does Dr Vishal Pai consult and operate?
Dr Vishal Pai consults at Sandringham Orthopaedic Specialists, Suite 1, 60 Bay Road, Sandringham. He operates at Calvary Holmesglen Private Hospital, 490 South Road, Moorabbin, and The Avenue Hospital, 40 The Avenue, Windsor. Patients come from across Bayside, Glen Eira and the Mornington Peninsula, and some travel from regional Victoria. For consultation fees, see appointments and fees.
References
Show all 17 referencesHide references
- Saltzman B et al. 2017. A systematic review of 21 tibial tubercle osteotomy studies and more than 1000 knees: indications, clinical outcomes, complications, and reoperations. American Journal of Orthopedics.
- DeNovio AC et al. 2025. Incidence of complications, recurrent instability, and all-cause reoperations after tibial tubercle osteotomy for patellofemoral instability: a systematic review and meta-analysis of the literature. Orthopaedic Journal of Sports Medicine.
- Huntington LS et al. 2019. Factors associated with an increased risk of recurrence after a first-time patellar dislocation: a systematic review and meta-analysis. The American Journal of Sports Medicine.
- Franciozi C et al. 2019. Anteromedial tibial tubercle osteotomy improves results of medial patellofemoral ligament reconstruction for recurrent patellar instability in patients with tibial tuberosity-trochlear groove distance of 17 to 20 mm. Arthroscopy.
- Guevel B et al. 2023. Does tibial tuberosity osteotomy improve outcomes when combined with medial patellofemoral ligament reconstruction in the presence of increased tibial tuberosity–trochlear groove distance? A systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine.
- Knapik D et al. 2021. Radiographic and clinical outcomes after tibial tubercle osteotomy for the treatment of patella alta: a systematic review and meta-analysis. The American Journal of Sports Medicine.
- Stokes DJ et al. 2024. Tibial tubercle osteotomy: indications, outcomes, and complications. Current Reviews in Musculoskeletal Medicine.
- Li ZI et al. 2024. Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy.
- Liu JN et al. 2017. Return to sports after tibial tubercle osteotomy for patellofemoral pain and osteoarthritis. Arthroscopy.
- Lehane KM et al. 2024. Predictors of increased complication rate following tibial tubercle osteotomy (TTO). The Knee.
- Payne J et al. 2015. The incidence of complications of tibial tubercle osteotomy: a systematic review. Arthroscopy.
- Davis MA et al. 2025. Pain and hardware removal after tibial tubercle osteotomy: incidence, associated factors, and outcomes. Orthopaedic Journal of Sports Medicine.
- Shah AK et al. 2024. Incidence of complications after tibial tubercle osteotomy and tibial tubercle osteotomy with distalization. The American Journal of Sports Medicine.
- Moran T et al. 2024. Tibial tubercle osteotomies performed in an outpatient setting have a low rate of early complications. Arthroscopy, Sports Medicine, and Rehabilitation.
- Rood A et al. 2020. A detaching, V-shaped tibial tubercle osteotomy is a safe procedure with a low complication rate. Archives of Orthopaedic and Trauma Surgery.
- Lundeen A et al. 2022. High incidence of complication following tibial tubercle surgery. Journal of ISAKOS.
- Hinkley P et al. 2022. Patellar tendon imbrication for the treatment of patella alta in skeletally immature patients. Arthroscopy Techniques.
Frequently asked questions
Is a tibial tubercle osteotomy a major operation?
It’s a bigger operation than an MPFL reconstruction on its own, because a piece of bone is cut, moved and fixed with a plate and screws. Most people go home the morning after surgery and walk with crutches for about 6 weeks while the bone heals.
Is a tibial tuberosity transfer the same thing?
Yes. Tibial tubercle osteotomy, tibial tuberosity osteotomy and tibial tuberosity transfer all mean moving the bony attachment of your kneecap tendon. A Fulkerson osteotomy (anteromedialisation) is one type, which moves the bump inwards and forwards.
Will the plate and screws need to come out?
Can a teenager have a tibial tubercle osteotomy?
Usually not until growth has finished. The growth plate at the top of the shin sits close to the bump, and cutting near it while it’s still open can affect how the shin grows [17]. For younger people, Dr Vishal Pai will talk through other options, such as an MPFL reconstruction on its own.
Next step
Talk through your options
If your kneecap keeps dislocating, Dr Vishal Pai can examine your knee, review your scans and explain whether a tibial tubercle osteotomy would help, and what your other options are, including treatment without surgery.