Tibial Tubercle "Crest" Osteotomy (TCO) a modification of the classical Tibial Tubercle Osteotomy allows safe and easy extensile knee exposure

Background: Revision total knee arthroplasty requires extensile surgical exposure to ensure component explantation and debridement while maintaining extensor mechanism integrity. Traditional soft tissue procedures may lead to patellar tendon avulsion or extensor lag, while conventional tibial tubercle osteotomy fixation using screws or cerclage wires is frequently associated with hardware-related complications, anterior knee pain, and fragment migration.

Objective: This article describes a modified, low-energy tibial crest osteotomy (TCO) technique utilizing suture fixation to facilitate reproducible surgical access and immediate postoperative mobilization in complex revision knee surgery.

Key Points: The TCO involves a coronal plane osteotomy of the tibial tubercle, typically 6 to 8 cm in length, performed using multiple osteotomes to avoid thermal necrosis. A critical technical requirement is the preservation of the lateral soft tissue sleeve, which acts as a vascularized hinge to promote bone union and provide dynamic stability. Fixation is achieved by reducing the fragment in extension and securing it with heavy non-absorbable braided polyester sutures passed through 2 mm drill holes in the segment and tibial medulla. Clinical data from 181 cases demonstrated a 100% union rate at a mean of 11 weeks, with no reported extensor mechanism failures. The technique allows for immediate weight-bearing and full range of motion without bracing.

Conclusion: Tibial crest osteotomy with ligature closure provides a stable, hardware-free alternative for extensile exposure. By adhering to low-energy principles and preserving lateral vascularity, surgeons can achieve predictable bone healing and excellent clinical outcomes in complex revision scenarios.