Biomechanical analysis of flat and oblique tibial tubercle osteotomy for recurrent patellar instability

Both flat (Elmslie-Trillat) and oblique (Fulkerson) osteotomy techniques are successful in treating patellar instability episodes by moving the tibial tubercle medially. The oblique osteotomy also results in anterior displacement that decreases patellofemoral forces. Recent reports have described proximal tibial fractures occurring during early weightbearing after oblique osteotomy. We performed oblique and flat osteotomies on 13 pairs of fresh-frozen cadaveric knees. The knees were then tested to failure on a materials testing system by exerting a load through the quadriceps tendon at a rate of 1000 N/sec to simulate a stumble injury. The failure mechanism for flat osteotomies was more likely to be tubercle "shingle" fracture, while oblique osteotomies more frequently failed through a tibial fracture or fixation failure in the posterior tibial cortex. Mean load to failure was significantly higher in the flat osteotomy specimens (1639 N versus 1166 N), as was total energy to failure (224 N.m versus 127 N.m). There was no significant difference in stiffness (87 N/cm versus 74 N/cm). We recommend the flat osteotomy for patients with isolated recurrent patellar instability and the oblique osteotomy in patients who have concomitant patellofemoral pain or articular degenerative changes. When an oblique osteotomy is used, we recommend postoperative brace protection and restricted weightbearing until the osteotomy heals.