Dr. Garcia demonstrates his technique for tibial tubercle osteotomy with distalization.

In this video, Dr. Grant H. Garcia demonstrates a complex knee reconstruction procedure focusing on a Tibial Tubercle Osteotomy (TTO) with Distalization. This surgery is performed on a patient suffering from patella alta—a condition where the kneecap sits abnormally high in the joint, leading to severe instability, tracking issues, and pain. By surgically moving the bone anchor downward, the procedure restores the kneecap to its proper anatomical alignment.

Surgical Process Breakdown

• Exposure and Soft Tissue Preparation: The surgeon begins with a standard midline incision. Because this patient is undergoing a combination of procedures—including an MPFL (Medial Patellofemoral Ligament) reconstruction and a MACI (Matrix-induced Autologous Chondrocyte Implantation) cartilage repair—the incision is slightly wider. Dr. Garcia frees up the soft tissues on both the inner (medial) and outer (lateral) sides of the tibial tubercle, using an elevator tool to clear a clean space around the back of the bone.
• Protecting the Patellar Tendon: Using scissors, the surgeon carefully clears out fat pad tissue and separates the soft tissues directly surrounding the patellar tendon to ensure it remains completely safe and uninjured during the bone-cutting phase.
• Setting the Cutting Guide: A specialized centering guide system is aligned over the tibia. Dr. Garcia inserts three breakaway pins into the bone to firmly lock the heavy cutting jig in place. He uses a 45-degree angle configuration, which allows the forthcoming bone cut to accommodate both an inward shift (medialization) and a slight forward shift (anteriorization) of the kneecap.
• Executing the Precision Diamond Cut: Using a surgical saw blade, the surgeon performs a highly technical, angled "diamond cut" into the tibia. To minimize the risk of a post-operative tibia fracture, the saw cuts all the way through the bone at the lower end, but intentionally stops short of penetrating the far back cortex at the top end. The final release is achieved by turning the blade sideways to make a clean horizontal snap.
• Measuring and Shifting the Tubercle (Distalization): With the tibial tubercle bone block now fully mobile but still attached to the patellar tendon, Dr. Garcia references pre-operative measurements to shift the bone segment exactly one centimeter downward (distalized). This deliberate adjustment effectively corrects the high-riding kneecap and normalizes the patient's joint ratios.
• Rigid Hardware Fixation: The shifted bone block is provisionally secured with a temporary pin before being permanently locked down using large 4.5mm cannulated bone screws. The screws are angled outward to maximize grip. On the lowest screw, Dr. Garcia deliberately omits a metal washer because the patient's bone density is excellent; leaving the washer off prevents the hardware from feeling like a prominent, irritating bump under the skin later.
• Finalizing and Biocompatible Grafting: To promote rapid bone healing and fusion, the gaps around the newly repositioned bone block are packed tightly with Demineralized Bone Matrix (DBM) putty. Finally, Dr. Garcia takes the knee through a physical range of motion to confirm the screws are locked, the joint tracks beautifully, and any prominent bony edges are smoothed down with the saw to prevent skin irritation.