Malalignment and Overload Syndromes

  • Brandon J. Erickson
  • Andreas H. Gomoll


Anterior knee pain is one of the most common complaints that orthopedic surgeons evaluate patients for. Several conditions can cause anterior knee pain including imbalance between the quadriceps and hamstrings, patellofemoral instability, chondral wear on patella or trochlea, and lateral retinacular tightness. Fixed lateral patellar tilt due to excessive lateral retinacular tightness can result in overload of the lateral patellofemoral joint, leading to chondral degeneration and pain. Although nonsurgical treatment can frequently alleviate symptoms in the short term, patients presenting with chondral damage secondary to overload often require surgical intervention to obtain long-lasting pain relief and functional improvement. This treatment comes in the form of a tibial tubercle osteotomy with or without other concomitant procedures. This chapter will discuss the pathogenesis, diagnosis, surgical treatment, complications, and outcomes of lateral patella and trochlea overload treated with tibial tubercle osteotomy (TTO).


Tibial tubercle osteotomy (TTO) Pain Patellofemoral Knee 


  1. 1.
    Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64(4):393–400.PubMedGoogle Scholar
  2. 2.
    Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br. 1984;66(5):685–93.CrossRefGoogle Scholar
  3. 3.
    Ebert JR, Fallon M, Smith A, Janes GC, Wood DJ. Prospective clinical and radiologic evaluation of patellofemoral matrix-induced autologous chondrocyte implantation. Am J Sports Med. 2015;43(6):1362–72.CrossRefGoogle Scholar
  4. 4.
    Erickson BJ, Mascarenhas R, Sayegh ET, et al. Does operative treatment of first-time patellar dislocations lead to increased patellofemoral stability? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31:1207–15.CrossRefGoogle Scholar
  5. 5.
    Petersen W, Ellermann A, Gosele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264–74.CrossRefGoogle Scholar
  6. 6.
    Saper MG, Shneider DA. Diagnosis and treatment of lateral patellar compression syndrome. Arthrosc Tech. 2014;3(5):e633–8.CrossRefGoogle Scholar
  7. 7.
    Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42:2006–17.CrossRefGoogle Scholar
  8. 8.
    van Middelkoop M, van der Heijden RA, Bierma-Zeinstra SMA. Characteristics and outcome of patellofemoral pain in adolescents: do they differ from adults? J Orthop Sports Phys Ther. 2017;47(10):801–5.CrossRefGoogle Scholar
  9. 9.
    Fu FH, Maday MG. Arthroscopic lateral release and the lateral patellar compression syndrome. Orthop Clin North Am. 1992;23(4):601–12.PubMedGoogle Scholar
  10. 10.
    Grawe B, Stein BE. Tibial tubercle osteotomy: indication and techniques. J Knee Surg. 2015;28(4):279–84.CrossRefGoogle Scholar
  11. 11.
    Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop Relat Res. 1979;144:9–15.Google Scholar
  12. 12.
    Paulos LE, O’Connor DL, Karistinos A. Partial lateral patellar facetectomy for treatment of arthritis due to lateral patellar compression syndrome. Arthroscopy. 2008;24(5):547–53.CrossRefGoogle Scholar
  13. 13.
    Lewallen DG, Riegger CL, Myers ER, Hayes WC. Effects of retinacular release and tibial tubercle elevation in patellofemoral degenerative joint disease. J Orthop Res. 1990;8(6):856–62.CrossRefGoogle Scholar
  14. 14.
    Beck PR, Thomas AL, Farr J, Lewis PB, Cole BJ. Trochlear contact pressures after anteromedialization of the tibial tubercle. Am J Sports Med. 2005;33(11):1710–5.CrossRefGoogle Scholar
  15. 15.
    Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;18(5):490–6. discussion 496-497CrossRefGoogle Scholar
  16. 16.
    Saranathan A, Kirkpatrick MS, Mani S, et al. The effect of tibial tuberosity realignment procedures on the patellofemoral pressure distribution. Knee Surg Sports Traumatol Arthrosc. 2012;20(10):2054–61.CrossRefGoogle Scholar
  17. 17.
    Yang JS, Fulkerson JP, Obopilwe E, et al. Patellofemoral contact pressures after patellar distalization: a biomechanical study. Arthroscopy. 2017;33(11):2038–44.PubMedGoogle Scholar
  18. 18.
    Cotter EJ, Waterman BR, Kelly MP, Wang KC, Frank RM, Cole BJ. Multiple osteochondral allograft transplantation with concomitant tibial tubercle osteotomy for multifocal chondral disease of the knee. Arthrosc Tech. 2017;6(4):e1393–8.CrossRefGoogle Scholar
  19. 19.
    von Keudell A, Han R, Bryant T, Minas T. Autologous chondrocyte implantation to isolated Patella cartilage defects. Cartilage. 2017;8(2):146–54.CrossRefGoogle Scholar
  20. 20.
    Yanke AB, Wuerz T, Saltzman BM, Butty D, Cole BJ. Management of patellofemoral chondral injuries. Clin Sports Med. 2014;33(3):477–500.CrossRefGoogle Scholar
  21. 21.
    Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP. Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am J Sports Med. 1997;25(4):533–7.CrossRefGoogle Scholar
  22. 22.
    Guillamon JL, Lord G, Marotte JH, Blanchard JP. Treatment of patello-femoral arthrosis by anterior displacement of the tibial tuberosity (Maquet procedure). Rev Chir Orthop Reparatrice Appar Mot. 1977;63(6):545–62.PubMedGoogle Scholar
  23. 23.
    Hirsh DM, Reddy DK. Experience with Maquet anterior tibial tubercle advancement for patellofemoral arthralgia. Clin Orthop Relat Res. 1980;148:136–9.Google Scholar
  24. 24.
    Fisher TF, Waterman BR, Orr JD, Holland CA, Bader J, Belmont PJ Jr. Tibial tubercle osteotomy for patellar chondral pathology in an active United States military population. Arthroscopy. 2016;32(11):2342–9.CrossRefGoogle Scholar
  25. 25.
    Liu JN, Wu HH, Garcia GH, Kalbian IL, Strickland SM, Shubin Stein BE. Return to sports after tibial tubercle osteotomy for patellofemoral pain and osteoarthritis. Arthroscopy. 2018;34:1022–9.CrossRefGoogle Scholar
  26. 26.
    Rosso F, Rossi R, Governale G, et al. Tibial tuberosity anteromedialization for patellofemoral chondral disease: prognostic factors. Am J Sports Med. 2017;45(7):1589–98.CrossRefGoogle Scholar
  27. 27.
    Saltzman BM, Rao A, Erickson BJ, et al. A systematic review of 21 Tibial tubercle osteotomy studies and more than 1000 knees: indications, clinical outcomes, complications, and reoperations. Am J Orthop (Belle Mead NJ). 2017;46(6):E396–407.Google Scholar
  28. 28.
    Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes. Clin Orthop Relat Res. 2007;463:187–94.PubMedGoogle Scholar
  29. 29.
    Erickson BJ, Tilton A, Frank RM, Park W, Cole BJ. Rates of deep vein thrombosis occurring after osteotomy about the knee. Am J Orthop (Belle Mead NJ). 2017;46(1):E23–7.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Brandon J. Erickson
    • 1
  • Andreas H. Gomoll
    • 1
  1. 1.Hospital for Special Surgery, Division of Sports and ShoulderNew YorkUSA

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