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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.

OBJECTIVE: There is growing interest in tibial tubercle fractures in pediatric and adolescent population within the last decade. However, there is limited evidence in the existing literature. Therefore, the purpose of this systematic review was to analyze and provide up-to-date data that may prove valuable in decision making and management of these injuries in the general as well as the athletic population.
METHODS: A systematic review of the literature in PubMed, Cochrane library and Virtual Health Library was conducted using the \"Preferred Reporting Items for Systematic Reviews and Meta-Analysis\" (PRISMA) guidelines. Articles published in English or Spanish, during the past 20 years, reporting outcomes of tibial tubercle fracture management in patients younger than 18 years old, with a mean follow-up of at least 6 months reporting outcomes, type of management and classification were included.
RESULTS: A total of 919 patients with 956 fractures in 25 retrospective cohort studies were included. The mean age was 14.4 ± 0.6 years while 766 [83%] were males and 740 [81%] of the injuries were sports-related. Associated injuries were reported in 91[10%] cases, most common being patellar tendon avulsion. Surgical management was chosen for 845[88%] of the cases, the vast majority being open reduction internal fixation (ORIF) with screws. Union was achieved in 954 [99.8%] cases. Complications and re-operations rate stood at 172[18%] and 161 [19% of the operations], respectively. Return to play (RTP) was reported in 11 [44%] of the studies standing at an average of 98.9% ± 3.6.
CONCLUSIONS: Essentially, this is an adolescent sports knee injury that needs careful planning before decision making because it may affect both RTP and joint preservation. Although union was achieved in almost all patients, there is a high risk of associated injuries, complications and reoperations. The surgeon should be confident to perform fracture fixation as well as addressing associated knee soft tissue injuries to achieve optimal outcomes.
METHODS: Level IV.

The tibial tubercle to trochlear groove (TT-TG) distance is often utilized for determining the surgical treatment for patients with patellar instability (PI). It is thought to directly represent the position of the TT on the tibia. Recent work has shown that the measurement of the TT-TG distance is multifactorial.
To investigate the relationship between relative tibial external rotation (rTER) and trochlear dysplasia (TD), as well as the location of the TG and TT in patients with and without PI, and to correlate these and other anatomic measurements with the TT-TG distance.
Cross-sectional study; Level of evidence, 3.
A total of 89 patients with PI who underwent magnetic resonance imaging were identified with 92 matched control patients. A standardized measurement protocol on axial magnetic resonance imaging determined rTER, the proximal and distal TG lateralization (pTGL and dTGL, respectively) ratios, and the TT lateralization (TTL) ratio. Other measures of interest included the lateral trochlear inclination angle, sulcus angle, and lateral patellar inclination angle. Univariate regression was used to determine the associations of TD (lateral trochlear inclination angle, sulcus angle) with rTER and the TG position, and multivariate regression was used to model associations among all the variables with the proximal and distal TT-TG distances.
rTER was significantly higher in the study group (P < .001), and univariate regression showed a significant association between dysplasia measures and rTER (P < .001). The pTGL ratio was lower in the study group (P = .025), but there was no difference in the dTGL ratio (P = .090) or the TTL ratio (P = .098) between the groups. There were no associations between dysplasia measures and the pTGL and dTGL ratios (P > .05). Multivariate regression showed that the proximal TT-TG distance is predicted by the sulcus angle, pTGL ratio, rTER, and TTL ratio (P < .05) and that the distal TT-TG distance is predicted by the lateral patellar inclination angle, dTGL ratio, sulcus angle, rTER, and TTL ratio (P < .05).
rTER had a significant association with TD. The position of the proximal TG was more medial in patients with PI. There was no significant difference in the TTL ratio between patients with and without PI. The TT-TG distance was associated with multiple anatomic measures and was not solely predicated on the position of the TT.

OBJECTIVE: Medial opening wedge high tibial osteotomy (MOWHTO) is a mainstream surgical method for treating early medial compartment knee osteoarthritis. Undesirable sequelae such as patella infera may happen following tuberosity osteotomy. We conducted this systematic review and meta-analysis to compare the change in patellar position after proximal tibial tubercle osteotomy (PTO) versus distal tibial tubercle osteotomy (DTO) intervention.
METHODS: The 11 studies were acquired from PubMed, Medline, Embase and Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed by RevMan5.3. Mean differences, odds ratios and 95% confidence intervals were calculated. Cochrane Collaboration\'s Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias.
RESULTS: Eleven observational studies were assessed. The methodological quality of the trials ranged from moderate to high. The pooled results of postoperative patellar height (Caton-Deschamps index and Blackburne-Peel index) and postoperative complications showed that the differences were statistically significant between PTO and DTO interventions. Patellar index ratios decreased significantly in the PTO groups, and 12 (9.2%) complications under DTO surgery and 2 (1.6%) complications under PTO surgery were reported. The differences of postoperative posterior tibial slope (angle) was not statistically significant, but postoperative posterior tibial slope of both groups increased. Sensitivity analysis proved the stability of the pooled results and the publication bias was not apparent.
CONCLUSIONS: DTO in MOWHTO maintained the postoperative patellar height, and clinically, for patients with serious patellofemoral osteoarthritis, DTO can be preferred. Postoperative complications are easily preventable with caution. In view of the heterogeneity and small sample size, whether these conclusions are applicable should be further determined in future studies.

The tip of the tibial tubercle (TTT) is used to assess tibial baseplate rotation in total knee arthroplasty (TKA); however, it can be difficult to palpate and visualize intraoperatively. Several more easily accessible soft-tissue structures have been proposed as intraoperative assessments, including the patellar tendon\'s medial border (MBPT) and the junction of the medial third of the patellar tendon (mt-PT). No studies have described the relationship between the TTT and these proposed landmarks. The aims of the study were to (1) determine the relationship of the soft-tissue landmarks to the TTT and (2) identify any sex differences in these measures. Measurements of the position of these soft-tissue landmarks relative to the TTT were made on 56 cadaveric knees (28 female) by two observers at the level of the standard tibial cut (10 mm distal to the lateral tibial plateau). The results obtained were compared by sex and side. On average, 50.7% (SD 6.79, range 33.1%-63.1%) of the patellar tendon footprint was medial to the TTT. There were no significant differences between the sexes or left and right lower limbs. However, there was large variability in the position of all the soft-tissue landmarks relative to the TTT. The results indicate that, on average, the patellar tendon footprint is evenly spread around the TTT. However, there is a large variability in the anatomical relationship between the soft-tissue landmarks and the TTT. Caution is advised if relying on these structures intraoperatively.

Tibial tubercle osteotomy (TTO) is indicated to treat patellofemoral (PF) malalignment and chondral disease refractory to conservative treatment. However, there are no systematic reviews describing TTO outcomes in chondral damages without instability.
The aims of this study were to (1) assess the quality of the published studies, (2) identify indication for TTO to treat PFP with chondral disease without instability, (3) evaluate the most common TTO techniques, (4) evaluate the clinical outcomes, and (5) evaluate TTO\'s complication and failure rates.
In December 2020, a literature search was performed applying the following criteria: (1) peer-reviewed Level 1-4 studies; (2) English language; (3) human subjects with clinical and/or radiological outcomes; (4) TTO alone or associated with minor cartilage procedure (only drilling, no instability); (5) minimum follow-up 12 months, minimum 10 patients; and (6) no more than 20% of drop-out rate. Data from studies were collected and described with weighted averages and standard deviations.
A total of 18 Level 4 studies were included. The average Coleman Methodology Score was 61.5 points (range 48-81). A total of 851 patients (892 knees) were included, with 64.8% of female patients. The weighted average follow-up was 49.1 months (range 12-128.5). Indication for TTOs was poorly described. The main technique used was anteromedialisation (60.4%). In 27.7% of the cases, TTO was associated with lateral release. Different scoring systems were used to evaluate outcomes, with significant improvements. The average rate of good/excellent results was 78.7% (range 57%-100%). Fifteen studies described the complication rate (9.9%), whereas only four reported the failure rate (6.2%).
TTOs performed to treat PF malalignment associated with chondral disease without instability provided good clinical outcomes, with acceptable complication/failure rates. However, high-level studies are necessary because of studies\' heterogeneity regarding patellofemoral malalignment and chondral disease treatment.
Systematic review.

Level IV, systematic review of Level IV studies.

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.