Tibial Tubercle Osteotomy

Realigning the kneecap to reduce pain and prevent dislocations

Tibial Tubercle Osteotomy (TTO) is a surgical procedure used to realign the patella (kneecap) in order to improve knee stability, relieve pain, and prevent recurrent dislocations. The tibial tubercle is the bony prominence on the upper front part of the shinbone (tibia), where the patellar tendon attaches. In some patients, especially those with patellofemoral instability, maltracking, or alignment issues, the position of this bone contributes to knee pain and dysfunction.
TTO involves cutting and repositioning the tibial tubercle to change the line of pull of the patellar tendon, helping to centralise the kneecap within the groove of the femur during movement. It is often performed alongside other procedures such as cartilage restoration or patellofemoral joint stabilisation, depending on the patient’s individual anatomy and underlying issues.

This page provides an in-depth overview of TTO surgery, including when it may be recommended, what to expect before and after surgery, and how Dr George Awwad uses this approach as part of a personalised treatment plan to preserve knee function and prevent future complications.

What is a tibial tubercle osteotomy (TTO)?

A tibial tubercle osteotomy (TTO) is a surgical procedure that aims to correct the alignment of the patella (kneecap) by repositioning a section of bone at the top of the shinbone (tibia) called the tibial tubercle. This small bony prominence is where the patellar tendon attaches, playing a key role in the movement and stability of the kneecap.

When the patella does not track properly in the groove of the femur (thighbone), it can lead to pain, instability, and damage to the cartilage underneath the kneecap. TTO helps to address this by shifting the tibial tubercle in one or more directions, most commonly medially (inwards), anteriorly (forwards), or distally (downwards), to improve patellar alignment and reduce stress on the joint. This realignment procedure can be performed on its own or in combination with other surgeries such as medial patellofemoral ligament (MPFL) reconstruction or cartilage repair, depending on the individual’s specific condition. It is commonly used as part of the treatment plan for patellofemoral instability, maltracking, or chondral damage related to kneecap movement.

The ultimate goal of a TTO is to help stabilise the kneecap, relieve pain, improve knee function, and prevent further joint deterioration, particularly in active individuals or younger patients seeking to delay or avoid more extensive joint replacement procedures.

When might a TTO be recommended?

A tibial tubercle osteotomy (TTO) may be recommended when symptoms such as patellar instability, maltracking, or anterior knee pain are linked to abnormal positioning or alignment of the tibial tubercle, the bony prominence on the shinbone (tibia) where the patellar tendon attaches. This procedure aims to correct the alignment of the patella (kneecap) by repositioning the tibial tubercle, helping improve joint function and reduce mechanical stress within the knee.

TTO is often considered as part of a joint-preserving strategy, particularly for younger or active patients who have not responded to non-surgical treatment. It may also be recommended in combination with other surgical procedures, such as medial patellofemoral ligament (MPFL) reconstruction, to address patellofemoral instability more comprehensively.

Common scenarios where TTO may be considered:

Recurrent patellar dislocations or subluxations

Particularly when imaging studies reveal lateralisation of the tibial tubercle (i.e., an increased tibial tubercle–trochlear groove distance or “TT-TG” distance).

Patellar maltracking

Where the kneecap does not glide smoothly within its groove during movement, leading to pain, catching, or instability.

Patellofemoral joint overload or cartilage wear

In cases of early patellofemoral arthritis or cartilage damage isolated to specific areas that may benefit from unloading through realignment.

Abnormal biomechanics or alignment

Such as patella alta (a high-riding patella) or excessive lateral force vectors that contribute to chronic knee pain or instability.

Failed previous soft tissue procedures

In patients who have undergone lateral release or MPFL repair without adequate resolution of symptoms.

During your consultation, Dr George Awwad will assess your symptoms, review imaging studies such as X-rays and MRI scans, and evaluate alignment metrics such as the TT-TG distance and patellar height. He will provide personalised advice on whether a TTO is appropriate for your condition, and whether it should be performed as a standalone procedure or in combination with other stabilisation techniques.

Who might be suitable for TTO surgery?

Tibial tubercle osteotomy (TTO) may be suitable for patients who experience ongoing patellofemoral joint issues such as instability, maltracking, or anterior knee pain — and have underlying alignment abnormalities that contribute to their symptoms. TTO is often considered in younger or active patients, particularly when conservative treatments such as physiotherapy, activity modification, or bracing have not provided adequate symptom relief. The goal of the procedure is to correct the position of the tibial tubercle to improve patellar tracking, reduce mechanical overload, and support long-term joint preservation.

You may be a candidate for TTO if:

You have recurrent patellar dislocation or subluxation

And imaging confirms abnormal alignment such as an increased TT–TG (tibial tubercle–trochlear groove) distance or patella alta.

You experience persistent patellofemoral pain or maltracking

Especially if it limits your activity and has not responded to non-surgical care.

You have focal cartilage wear or early patellofemoral arthritis

That may benefit from unloading or shifting pressure away from the damaged region.

You have anatomical factors contributing to instability

Such as lateralised tibial tubercle positioning or high-riding patella.

You are physically active and motivated to pursue rehabilitation

As TTO surgery requires a structured recovery program, including physiotherapy and a temporary reduction in weight-bearing.

You have failed prior soft tissue procedures

Including lateral release or isolated MPFL reconstruction without addressing bony alignment issues.

During your consultation, Dr George Awwad will perform a detailed clinical assessment and review imaging, including X-rays, CT scans, or MRI, to evaluate your alignment and joint condition. Measurements such as the TT–TG distance, patellar height (Caton–Deschamps Index), and trochlear shape will help determine whether TTO is appropriate and whether it should be combined with other procedures such as MPFL reconstruction or cartilage restoration. Dr Awwad will also consider your goals, age, activity level, and overall knee health to provide individualised surgical recommendations.

Who may not be suitable for this procedure?

Tibial tubercle osteotomy (TTO) is not appropriate for every patient with anterior knee pain or patellofemoral instability. In some cases, alternative surgical or non-surgical treatments may be more suitable, depending on your overall knee condition, activity level, and goals.

TTO may not be suitable if you have:

Advanced patellofemoral arthritis

In cases where the cartilage damage is widespread and severe, TTO may not provide sufficient symptom relief. Other surgical options such as patellofemoral joint replacement may be considered.

Diffuse or tricompartmental knee arthritis

TTO is designed to address issues in the patellofemoral joint. If you have arthritis affecting the entire knee (including the medial and lateral compartments), knee replacement surgery may be more appropriate.

Poor bone quality or osteoporosis

The success of TTO depends on stable bone fixation and healing. Significantly reduced bone density may increase the risk of fracture or fixation failure.

Open growth plates (skeletal immaturity)

In younger patients who have not yet completed bone growth, TTO is generally avoided due to the risk of growth disturbance. Other alignment procedures may be considered instead.

Infection or active inflammatory joint disease

Ongoing joint or bone infection, or poorly controlled autoimmune conditions affecting the knee, may increase the risk of post-operative complications and poor healing.

Unwillingness or inability to follow rehabilitation protocols

TTO requires a structured rehabilitation process, including physiotherapy and limited weight-bearing during the early recovery phase. If these guidelines cannot be followed, surgical outcomes may be compromised.

Dr Awwad will take the time to understand your unique circumstances, including your imaging results, lifestyle goals, and overall joint health. If TTO is not appropriate for your condition, he will discuss other treatment pathways that may better support your long-term knee function and quality of life.

Tibial tubercle realignment techniques: medialisation, anteriorisation, distalisation

Tibial tubercle osteotomy (TTO) is a procedure that allows the position of the patellar tendon’s attachment on the shin bone (tibia) to be altered. This realignment helps to improve how the kneecap (patella) tracks in the groove of the thighbone (femur), reducing pain and instability.

There are three main directions the tibial tubercle may be moved during surgery, depending on your specific condition:

1. Medialisation

This involves shifting the tibial tubercle towards the inner side (medial side) of the leg.

Purpose: To correct lateral (outer) patellar tracking or recurrent dislocation.
How it helps: Medialisation repositions the pull of the patellar tendon, helping to keep the kneecap more centred within the femoral groove during movement.
Often used for: Patients with patellar instability, lateral maltracking, or abnormal tibial tubercle–trochlear groove (TT–TG) distance.

2. Anteriorisation

This technique shifts the tubercle forward (anteriorly).

Purpose: To reduce pressure on the undersurface of the kneecap.
How it helps: Anteriorisation unloads the patellofemoral joint, which may reduce pain and inflammation in patients with early cartilage wear or chondral defects.
Often used for: Individuals with patellofemoral pain syndrome, chondromalacia patellae, or focal cartilage defects.

3. Distalisation

Distalisation lowers the tibial tubercle, moving it downward toward the foot.

Purpose: To correct a high-riding patella (patella alta), which can impair engagement with the trochlear groove.
How it helps: This improves the patella’s contact with the femur during knee flexion, supporting better joint stability and function.
Often used for: Patients with patella alta and recurrent dislocations.

Tailoring the approach to your anatomy

In many cases, a combination of movements such as anteromedialisation (forward and inward) may be used to achieve optimal alignment and joint load distribution. Dr George Awwad uses detailed imaging and measurements, including TT–TG distance and patella height, to plan the direction and degree of adjustment that best matches your knee’s anatomy and surgical goals. This precise, personalised approach supports better outcomes in stability, pain relief, and long-term joint preservation.

TTO vs MPFL Reconstruction vs Lateral Release: how do they differ?

Tibial tubercle osteotomy (TTO), medial patellofemoral ligament (MPFL) reconstruction, and lateral release are all surgical procedures that may be used to address patellar instability, maltracking, or kneecap pain. Each procedure targets a different part of the knee’s anatomy and is chosen based on the underlying cause of symptoms.

Below is a breakdown of how each technique differs in purpose and approach:

1. Tibial Tubercle Osteotomy (TTO)

2. MPFL Reconstruction

3. Lateral Release

Note: Lateral release is less commonly performed in isolation today, as it may be insufficient on its own and can lead to instability if overused. It is sometimes performed in combination with TTO or MPFL reconstruction.

Selecting the right procedure

In some cases, a combination of these procedures may be recommended to address both soft tissue and bony alignment issues. For example:

Dr George Awwad will assess your knee’s specific anatomy using imaging (such as X-rays and MRI) and measurements like TT–TG distance, patella height, and the condition of ligaments and cartilage. Based on this, he will recommend the most appropriate approach tailored to your situation.

What happens during the tibial tubercle osteotomy surgery?

Tibial tubercle osteotomy (TTO) is a surgical procedure that aims to improve the alignment of the kneecap (patella) by repositioning the tibial tubercle, the bony prominence on the upper front part of the shinbone where the patellar tendon attaches. Repositioning this bony attachment changes the way the patella tracks in the groove of the femur, which may help reduce pain, improve stability, and prevent further joint damage.

Below is an overview of the key steps involved in the procedure:

1. Anaesthesia and positioning

The surgery is typically performed under general anaesthesia. You may also receive a regional nerve block to assist with pain control after surgery. Once anaesthetised, your leg is prepared and draped in a sterile fashion. You’ll be positioned to allow access to the front of the knee.

2. Surgical incision

A vertical incision is made along the front of the upper shinbone, just below the knee. The surgeon carefully exposes the tibial tubercle, taking care to preserve surrounding tissues such as the patellar tendon and important nerves and blood vessels.

3. Cutting and mobilisation of the tibial tubercle

Using a surgical saw or osteotome, the tibial tubercle is precisely cut, leaving it attached to the patellar tendon. This bone fragment is then gently mobilised to allow movement into a new position, such as medially (towards the inner side of the knee), anteriorly (for reduced joint pressure), or distally (to address patella alta). The specific direction and amount of movement are based on your individual knee anatomy and surgical goals, often guided by pre-operative imaging and measurements (such as TT–TG distance and patellar height).

4. Repositioning and fixation

Once the tibial tubercle is correctly positioned, it is secured in place using surgical screws. These screws are typically made of metal and may remain in place permanently unless they cause symptoms later. In some cases, a small bone wedge may be used to support the new position, depending on the amount of movement required.

5. Additional procedures (if needed)

If required, other procedures may be performed during the same operation. These may include:

6. Wound closure and dressing

Once the osteotomy is stabilised and any additional procedures are completed, the incision is closed with dissolvable sutures or staples. A sterile dressing is applied, and a knee brace or splint may be fitted to protect the leg and control movement in the early post-operative period.

7. Post-operative care and monitoring

You’ll be transferred to recovery for monitoring as you wake from anaesthesia. Pain management, blood clot prevention, and early physiotherapy planning begin shortly after surgery. Most patients remain in hospital for 1–2 nights before being discharged home with detailed instructions for rehabilitation.

Dr George Awwad will guide you through your personalised post-operative plan, which includes physiotherapy, follow-up imaging, and progressive return to daily activities based on your surgical findings and goals.

What is the recovery process after TTO?

Recovery after a Tibial Tubercle Osteotomy (TTO) is a gradual, structured process designed to protect the surgical site, optimise healing, restore strength and function, and eventually support a safe return to daily and sporting activities. Recovery timelines can vary depending on your anatomy, the extent of the procedure, and whether additional procedures (such as MPFL reconstruction or lateral release) were performed. Dr George Awwad follows a detailed rehabilitation protocol that includes specific phases and guidance for weight-bearing, bracing, physiotherapy, and return to activity.

Initial recovery: first 1–3 weeks

Weight-bearing: You will typically begin with touch weight-bearing using crutches.
Knee brace: A hinged knee brace is worn at all times (except during hygiene routines) and is initially set to allow 0–30 degrees of movement.
Pain management: You’ll be prescribed pain relief and advised to use ice packs and leg elevation regularly to help manage swelling and discomfort.
Compression: White compression stockings may be used for the first 2 weeks to reduce the risk of blood clots.
Dressings: Bulky surgical dressings are removed the day after surgery, with smaller adhesive dressings kept intact. A wound check is arranged within 1–2 weeks.
Physiotherapy: Early, supervised physiotherapy begins immediately to minimise stiffness and promote safe movement. Exercises may include:

Weeks 4–6: Improving mobility and range of motion

Weeks 6–12: Building strength and movement

Imaging review: Before progressing, X-rays are used to confirm healing of the osteotomy site.
Weight-bearing: You may begin weight-bearing as tolerated (WBAT) and gradually wean off crutches as strength allows.
Brace: May be worn with increasing flexibility, eventually allowing 0–90 degrees of motion, then weaned off based on strength and stability.
Exercise progression: You may begin using:

Months 3–6: Return to function and low-impact activity

Months 6–9: Return to higher-level activity

9+ Months: Return to sport or demanding physical activity

Ongoing physiotherapy support

Physiotherapy plays a key role throughout each recovery phase. Dr Awwad recommends 6–12 months of supervised rehabilitation, which will be adjusted based on your progress and goals

What are the potential risks or complications of TTO?

As with any orthopaedic procedure, tibial tubercle osteotomy (TTO) carries certain risks and potential complications. While many patients recover well with appropriate rehabilitation, it’s important to be aware of possible challenges that may arise before, during, or after surgery. Dr George Awwad will discuss these risks with you during your consultation and answer any questions you may have as part of the informed consent process.

General surgical risks

These include risks common to most surgical procedures:

Infection

As with any surgery, there is a small risk of infection at the incision site or deeper within the joint or bone.

Bleeding or haematoma

Localised bleeding may occur during or after the procedure.

Blood clots (deep vein thrombosis or pulmonary embolism)

Measures such as compression stockings, early mobilisation, and medication may be used to reduce this risk.

Wound healing problems

Some patients may experience delayed healing or irritation at the incision site.

Risks specific to tibial tubercle osteotomy

Non-union or delayed union

The cut section of bone (osteotomy) may heal slowly or not fully unite. Additional treatment may be needed in rare cases.

Fracture

There is a risk of unintended fracture in the surrounding bone during or after the osteotomy.

Loss of fixation

The screws or hardware used to secure the tibial tubercle may become loose or shift if the bone is not adequately protected during recovery.

Hardware irritation

Some patients may feel the screws or plates under the skin. These can often be removed after the bone has healed if they cause discomfort.

Overcorrection or undercorrection

If the realignment is not optimal, symptoms such as instability or discomfort may persist.

Patella baja or alta

Changes in the height of the kneecap can occur if the osteotomy alters the patellar tendon length or alignment too significantly.

Functional complications

Persistent pain or stiffness: Some patients may experience ongoing discomfort or reduced knee motion after surgery.
Reduced strength or weakness: Temporary quadriceps weakness is common but usually improves with physiotherapy.
Nerve or vessel injury: Although rare, there is a small risk of injury to surrounding nerves or blood vessels.

Need for further surgery

In some cases, further surgery may be needed. This may include:

Dr Awwad will assess your anatomy, activity level, and specific condition to determine whether TTO is the most suitable treatment. He will also provide detailed post-operative instructions and a structured rehabilitation plan to help reduce your risk of complications and support an optimal outcome.

Tibial Tubercle Osteotomy FAQs

These frequently asked questions are designed to help you better understand tibial tubercle osteotomy surgery, recovery expectations, and how the procedure may support your long-term knee health:

What is a tibial tubercle osteotomy and why is it done?

Tibial tubercle osteotomy (TTO) is a surgical procedure that repositions the bony attachment of the patellar tendon to correct misalignment of the kneecap (patella). It is often recommended for patients with recurrent patellar instability, maltracking, or patellofemoral joint pain due to abnormal biomechanics.

How is the bone fixed in place during a TTO?

During the procedure, the tibial tubercle is carefully cut and moved to a new position (typically medialised, anteriorised, or distalised). It is then securely fixed in place using surgical screws. These screws are usually left in permanently but can be removed if they cause irritation once the bone has healed.

Does the bone grow back together after TTO surgery?

Yes, the bone typically heals over a period of 6 to 12 weeks. During this time, the bone gradually forms a solid union in the new position. Weightbearing is often limited initially to protect the healing site, and serial imaging may be used to confirm bone healing.

Will I need to wear a brace after TTO surgery?

Yes. Most patients are fitted with a knee brace immediately after surgery. This brace helps stabilise the knee, limits unwanted motion, and protects the osteotomy site while the bone heals. Your physiotherapist will guide you on how and when to adjust or remove the brace as you progress through rehabilitation.

How long will I be on crutches after a tibial tubercle osteotomy?

Crutches are typically required for around 6 weeks after surgery. Your weightbearing status will depend on the specific osteotomy performed, your bone healing progress, and any additional procedures carried out at the same time.

Can a TTO delay or prevent the need for knee replacement?

In certain cases, yes. When combined with other procedures (such as cartilage repair or realignment), a TTO can reduce abnormal loading on the patellofemoral joint and may help preserve knee function, potentially delaying the need for partial or total knee replacement in younger patients with isolated patellofemoral arthritis or malalignment.

When can I return to work after TTO surgery?

Return to work depends on your job type:

Dr Awwad will provide personalised guidance based on your role and recovery progress.

When can I drive after a TTO?

Driving is typically not recommended until you can safely bear weight, have sufficient range of motion, and can control the pedals without pain or delay. This usually occurs around 6–8 weeks after surgery, depending on whether your operative leg is the left or right side and whether your vehicle has manual transmission.

When can I return to sport after TTO surgery?

Return to sport varies depending on your healing, strength, and confidence:

What role does physiotherapy play after tibial tubercle osteotomy?

Physiotherapy is essential for regaining strength, flexibility, and joint control after surgery. Your rehab will progress through stages:

Will I need hardware removed after TTO surgery?

Most patients do not require hardware removal. However, if screws cause discomfort after the bone has fully healed, a minor procedure may be recommended to remove them. This typically occurs around 9–12 months post-op if needed.

If you’re living with pain or stiffness that’s affecting your quality of life, a thorough assessment can help determine the cause and guide the right treatment path.