Tibial tubercle avulsion fractures (TTAFs) are rare but typical in children and adolescents and Osgood-Schlatter disease (OSD) may be involved in their pathogenesis. However, few publications have reported the relationship between OSD and TTAF. A 16-year-old healthy male adolescent presented with pain, swelling and limited range of motion of the right knee following sudden acceleration while running. Based on the radiographic evidence, the patient was diagnosed with an avulsion fracture of the right tibial tubercle and OSD. Open reduction and internal fixation were performed using two cannulated screws and two Kirschner wires. The patient returned to preinjury activity levels at the 12-month follow-up postoperatively. This case report aimed to highlight this unique injury pattern. For patients with TTAFs, not only should the fracture be treated, but the cause of the fracture, such as OSD, should also be given appropriate treatment.

UNASSIGNED: Increased posterior tibial slope angle (PTSA) has been shown to be an important risk factor for anterior cruciate ligament (ACL) injury. PTSA modulation is not utilized routinely to reduce risk of primary rupture or graft failure. Displaced tibial tubercle (TT) fractures in the skeletally immature are associated with potential growth arrest and may be used as a model to study PTSA changes in this setting.
UNASSIGNED: To quantify the change in PTSA (ΔPTSA) after operative treatment of displaced TT fractures in skeletally immature patients. It was hypothesized that there would be a progressive decrease in PTSA after TT injury and that rate of ΔPTSA would be highest during peak growth velocity.
UNASSIGNED: Case series; Level of evidence, 4.
UNASSIGNED: Included were 22 patients (n = 23 knees; mean chronological and bone age at injury, 14 years; 86% male) who underwent surgery for displaced TT fracture. PTSA was measured on lateral radiographs at time of surgery and subsequent follow-up, and bone age at the time of injury was determined using radiographic standards. The rate of ΔPTSA for individual patient, total cohort, and sex-based subgroup trends were determined via linear regression (degrees per month; positive value indicates relatively anterior). Individual patient regression coefficients were averaged into bone age cohorts.
UNASSIGNED: Average follow-up was 17 months (range, 6-52 months). The mean PTSA was -12°± 2.4° at the time of injury, and the mean ΔPTSA for the cohort was 0.30°± 0.31° per month (range, -0.27° to 0.97° per month). Linear regression demonstrated a significant relationship between months postfixation and PTSA, demonstrating a ΔPTSA of 0.31° per month (95% confidence interval [CI], 0.24° to 0.38°; P < .001). The highest ΔPTSA was seen at bone age 14 years (mean, 0.58°± 0.44° per month). The mean absolute change in PTSA from injury to final follow-up was 4.1° (range, -3.4° to 21°).
UNASSIGNED: Our data suggested that PTSA becomes more anterior after operatively treated pediatric TT fractures and that ΔPTSA may be influenced by bone age. This concept may be useful in considering surgical modulation of excessive PTSA in the pediatric ACL-deficient knee.

BACKGROUND: In this study, the traditional \"Anatomical Landmark-Distance Method (AL-DM)\" in the formation of joint line (JL) was compared with \"Adductor Tubercle-Ratios method\" (AT-RM), and the effect of reestablishment of JL on clinical and functional outcomes were evaluated.
METHODS: 16 revision total knee arthroplasties (rTKAs) were performed by using \"AT-RM\" (group 1) and 16 rTKA by using \"AL-DM\" (group 2) in our clinic between 2015 and 2018. The data were prospectively collected and a total of 32 knees of 31 patients were analyzed. At the final follow-up, knee functions were evaluated by using Knee Society Score (KSS) knee and function, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, Short Form-36 (SF-36) questionnaires and physical examinations.
RESULTS: Postoperative flexion arc was higher in Group 1. KSS knee and function scores were better in group 1. In group1, JL was reestablished successfully in all revision rTKAs in terms of ATJL and the tibial tubercle TT-JL ratios. The improvement in KSS knee and function scores and WOMAC scores were also better in group 1. Measurements showed that the improvement in KSS scores increased as AT-JL and TT-JL distances approached the calculated values.
CONCLUSIONS: \"AT-RM\" was shown to be superior to the traditional distance method in terms of JL reestablishment. Functional results and patient satisfaction increased when JL was reestablished.

UNASSIGNED: Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue-based stabilization.
UNASSIGNED: To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta.
UNASSIGNED: Systematic review and meta-analysis; Level of evidence, 4.
UNASSIGNED: PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations.
UNASSIGNED: Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%).
UNASSIGNED: TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.

UNASSIGNED: Lower extremity genu varum is a common deformity leading to imbalanced weight distribution on the knee joint and eventually significant disabilities due to medial compartment joint osteoarthritis. This study was aimed to assess the efficacy of a novel technique of high tibial open wedge osteotomy plus tubercle osteotomy in a follow-up study.
UNASSIGNED: This is a prospective census cross-sectional study conducted on 146 patients with the history of genu varus undergone high tibial open-wedge osteotomy and tubercle osteotomy since 2011. The study population was followed within 6 months regarding tibial slope angle and medial proximal tibial angle alterations and operation-related complications, including venous phlebitis, nerve, and arterial injury, deep and superficial infection, mal-, non- and delayed-union.
UNASSIGNED: 146 patients with the mean age of 25.66 ± 4.23 years, and predominance of male gender (60.3%) were evaluated. Mean of tibia slope and MPTA before the surgical procedure was 9.38 ± 0.85 and 79.45 ± 2.11 that turned to 7.10 ± 0.84 and 89.74 ± 1.52 postoperatively, respectively (P < 0.001). Arterial and peroneal nerve injury was not detected in any of the cases. Deep-vein phlebitis, superficial infection, and delayed-union, malunion, and nonunion were presented in 2.05%, 1.36%, and 2.05%, respectively.
UNASSIGNED: Outcomes of this study showed significant improvement in the tibia slope angle and MPTA postoperatively. Surgical-associated complications were negligible and rehabilitated by performing appropriate medical/surgical approaches. Considering the number of assessed population, HTO plus tubercle osteotomy seems an acceptable approach for genu varum treatment.

OBJECTIVE: To perform a segmental analysis of tibial torsion in patients, with normal and increased external tibial torsion, suffering from chronic patellofemoral instability (PFI) and to investigate a possible correlation between tibial torsion and the position of the tibial tuberosity.
METHODS: Patients with chronic PFI who underwent torsional analysis of the lower limb using a standardized hip-knee-ankle MRI between 2016 and 2018 were included. For segmental analysis of tibial torsion, three axial levels were defined which divided the tibia into two segments: a distal, infratuberositary segment and a proximal, supratuberositary segment. Torsion was measured for the entire tibia (total tibial torsion, TTT), the proximal segment (proximal tibial torsion, PTT), and the distal segment (distal tibial torsion, DTT). Based on TTT, patients were assigned to one of two groups: Normal TTT (< 35°) or increased external TTT (> 35°). Position of the tibial tuberosity was assessed on conventional MRI scans by measuring the tibial tuberosity-trochlea groove (TT-TG) and the tibial tuberosity-posterior cruciate ligament (TT-PCL) distances.
RESULTS: Ninety-one patients (24 ± 6 years; 78% female) were included. Mean external TTT was 29.6° ± 9.1° and 24 patients (26%) had increased external TTT. Compared to patients with normal TTT, patients with increased external TTT demonstrated significantly higher values for DTT (38° ± 8° vs. 52° ± 9°; p < 0.001), whereas no difference was found for PTT ( - 13° ± 6° vs.  - 12° ± 6°; n.s.). Furthermore, a significant correlation was found between TTT and DTT (p < 0.001), whereas no correlation was found between TTT and PTT (n.s). With regard to TT-TG and TT-PCL distances, no significant differences were observed between the two groups (TT-TG: 15 ± 6 vs. 14 ± 4 mm, n.s.; TT-PCL: 22 ± 4 vs. 21 ± 5 mm, n.s.) and no correlation was found with TTT, DTT, or PTT (n.s.).
CONCLUSIONS: In patients with chronic PFI, increased external TTT of greater than 35° is an infratuberositary deformity and does not correlate with a lateralized position of the tibial tuberosity.
METHODS: Level III.

Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. Radiographs demonstrated a displaced fracture of the tibial tubercle; patellar tendon integrity could not be verified by ultrasonography. Intraoperatively, the patient was found to have a distal avulsion of the patellar tendon in addition to tubercle fracture. First, the tendon was secured to the tubercle fragment with transosseous sutures. A novel slotted-plate construct was used to fix the tubercle fragment prior to tightening the sutures. Postoperatively, the patient was permitted to bear weight as tolerated with the operative knee immobilized in extension. After six weeks, knee range of motion was gradually increased using a hinged brace. At one year, the patient had achieved excellent range of motion (full extension to 135 degrees of flexion) and strength (5/5 knee flexion and extension) without residual pain or complications. This case represents the first description of diagnosis, management, and rehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications.

BACKGROUND: Studies have shown that Q angle measurements were unreliable. Imaging studies have largely replaced the Q angle for measuring tibial tubercle lateralization. Creating a standardized protocol to measure the Q angle, with normative values, would provide a reliable reference without expensive imaging techniques.
METHODS: Thirty men and 27 women without history of knee problems or family history of dislocating kneecaps were subjects. Exclusion criteria were: patellofemoral abnormalities upon examination. We measured the Q angles of both knees using a standardized protocol and a long-armed goniometer. These data were analyzed to calculate normative values.
RESULTS: For all subjects, the mean was 14.8° (≈15°), 95% confidence interval (CI): ±5.4°. The male mean was 13.5°, 95% CI: ±5.2°. The female mean was 15.9°, 95% CI: ±4.8°. There was no significant difference between the right and left knees of the males (p = 0.52), nor of the females (p = 0.62), Beta = 0.14. The 2.4° difference between male and female means was due to the average height difference between the men and women.
CONCLUSIONS: This study provides a standardized Q angle measurement protocol to assess tibial tubercle lateralization at a patient\'s first encounter (and intra-operatively) without resorting to expensive imaging studies. These values provide a reliable reference for clinical comparison, and will allow all clinicians and sports medicine personnel to assess tubercle lateralization with reliability and validity. When using this protocol, the term \"Standard Q Angle\" (SQA) should be used, to avoid confusion with other measurement protocols.

BACKGROUND: In patients with recurrent patellar dislocations, a tibial tubercle osteotomy (TTO) can be indicated to correct patella alta or an increased trochlear groove-tibial tubercle distance. Several surgical techniques are described. Previous studies emphasize that detaching osteotomies results in devascularisation, which can lead to non-union and tibial shaft fractures. The aim of this study was to report the complication rates directly related to the surgical technique of a V-shaped TTO, where the tubercle is completely released from its periosteum using a step-cut osteotomy.
METHODS: The retrospective case series comprised a large cohort of 263 knees with patella alta in 203 patients who underwent a V-shaped TTO, with or without additional realignment procedures, between March 2004 and October 2017. Data were obtained from available patient files. Complications were defined as minor or major.
RESULTS: Thirteen major complications were registered (4.9%) including two tibial fractures (0.75%) and one non-union (0.37%). Five complications (1.9%) were defined as minor. Removal of the screws because of irritation or pain was seen in 22 cases (8.2%).
CONCLUSIONS: A V-shaped TTO is a safe procedure. The presumed higher risk for tibial fractures or pseudo-arthrosis could not be confirmed.

BACKGROUND: Most injuries in adolescent occur during school sports like volleyball, football or basketball. Tibial tubercle avulsion fractures (TTAF) are an unusual condition, resulting from a forced extension of the knee opposed to fixed leg.
UNASSIGNED: A 16 years old male was hurt during school basketball, X-rays displayed avulsion fracture of tibial tuberosity of left knee, the treatment was operative using two cancellous screws, results were good including complete knee mobility and early coming back to school sport at 6 months.
CONCLUSIONS: TTAF remains rare accounting for <3% of all epiphyseal injuries, it is frequent in teenage boys with open physis during school sport. We review the pathophysiology, mechanism, classification, diagnosis, and management of this injury.
CONCLUSIONS: complications are occasional and functional recuperation is common after closed reduction and cast immobilization for slightly or no displaced fractures, otherwise open reduction and internal fixation for displaced fractures.