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Distal Realignment Procedures1

Anatomy of the Tibial Tubercle

The tibial tubercle is a bony lump on the tibia (bone in the lower leg) below the kneecap. This serves as an attachment point for the patellar ligaments, tendons, and muscles. 

What is Distal Realignment?

Distal realignment procedures, also known as tibial tubercle transfer (TTT) procedures, are performed to reposition the kneecap after subluxation or dislocation by realigning the tendon under the kneecap to the underlying tibial tubercle. 

Distal Realignment Procedure

The distal realignment procedures include:

  • Maquet procedure: In this procedure, the tibial tubercle is cut, keeping the patellar tendon attachment intact. The tubercle is elevated by wedging the loosened piece of bone using a bone block. This procedure cannot move the tendon and tubercle medially (towards the inner aspect of the knee).
  • Elmslie-Trillat procedure: This is a procedure similar to the Maquet procedure, except that the tendon and tubercle can be moved medially.
  • Fulkerson procedure: In this procedure, the tibial tubercle is moved more towards the inner aspect of the knee. This is achieved by breaking the bone into sharp pieces (splintered), allowing the bits of bone and tendon to move more medially. After the procedure, the bits of bone are held in place using screws.
  • Hauser procedure: In this procedure, the tibial tubercle is moved medially, but not moved forward (anterior). Because of the shape of the tibia, the tubercle may shift its position more posteriorly (behind) and the patella may press down, causing pain.
  • Roux-Goldthwait procedure: It is a distal realignment procedure where the patellar tendon is split vertically. The lateral half of the patellar tendon is pulled under the inner half (medial) and attached to the tibia. This pulls the patella over to the center and helps prevent excess lateral shift.