Archives of Orthopaedic and Trauma Surgery (2018) 138:387–399
KNEE REVISION SURGERY
Tibial tubercle osteotomy (TTO) in total knee arthroplasty, is it
worth it? A review of the literature
· Andrea Camera
· Stefano Biggi
· Stefano Tornago
· Matteo Formica
· Lamberto Felli
Received: 27 June 2017 / Published online: 23 January 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Introduction Tibial tubercle osteotomy (TTO) is a well-established extensile approach to improve joint visualization and
implant removal. Despite this, TTO is a challenging technique with a long learning curve and potential pitfalls. Complica-
tions are not infrequent, even if performing the correct surgical steps. Aim of this paper is to review the current literature
about TTO, its safeness and reliability, and ﬁnally the complications rate.
Materials and methods We performed a systematic review of the available English literature, considering the outcomes and
the complications of TTO. The combinations of keyword were “tibial tubercle osteotomy”, “total knee arthroplasty”, “total
knee revision”, “outcomes”, “complication” and “surgical approach”.
Results From the starting 322 papers available, 26 manuscripts were ﬁnally included. Most of the papers show signiﬁcant
improvements in clinical outcomes, both in primary and in revision procedures. Radiographic fragment healing is close to
100%. Related complications can range from 3.8–20%.
Conclusion TTO may be necessary to correct pathological tuberosity position or patella tracking. However, TTO is a chal-
lenging technique to improve the surgical approach during total knee arthroplasty. A strict surgical technique can lead to
better results and to minimize complications. However, it is not clear if the improved outcome can outweigh the longer
surgery and the higher risk of pitfalls.
Keywords Tibial tubercle osteotomy · Total knee arthroplasty · Revision · Complications · Outcomes · Surgical approach
Nowadays total knee arthroplasty (TKA) is one of the most
widely performed procedures in orthopedics practice, prov-
ing remarkably successful in providing pain relief and restor-
ing joint function. Consequently, the requirement for revi-
sion total knee arthroplasty (RTKA) in the United States was
projected to grow by 601% between 2005 and 2030 . In
addition, the rate of re-revisions is also expected to increase,
with some studies showing a current ﬁgure in the range of
8–18% . The results after primary knee arthroplasty are
reasonably predictable and reproducible.
Revision knee arthroplasty is usually associated with
worse results than after primary arthroplasty . There are
many causes of failure of a TKA and the need for revision.
Determining the cause of failure is essential when planning
a revision procedure, since this will determine which com-
ponents require extraction and replacement; which surgical
approach should be performed; whether the procedure can
be performed as a one-stage or two-stage procedure; which
type of implant should be used; and how the patient can be
informed about the expected outcome . Moreover, having
a diagnosis before starting a revision is crucial. Revisions
performed for undiagnosed pain have worse results .
Lombardi et al.  found aseptic loosening was the major
reason of revision in terms of frequency (31.2%), followed
by instability (18.7%), infection (16.2%), polyethylene wear
(10.0%), arthroﬁbrosis (6.9%) and misalignment (6.6%).
Other probable causes are osteolysis, patella-femoral or
extensor mechanism problems and peri-prosthetic fracture.
Regardless of the cause of failure, the key to the success of
revision TKA is a safe surgical approach using an exposure
* Stefano Divano
Ospedale Policlinico San Martino, UO Clinica Ortopedica e
Traumatologica, largo R. Benzi 10, 16132 Genoa, GE, Italy
S.C. Chirurgia Protesica, Ospedale Santa Corona,
Pietra Ligure, SV, Italy