Surgery for patellofemoral pain is rarely required. The vast majority of patients are managed successfully with physiotherapy. If surgery is planned, this guide covers what to expect.
ℹ️ Surgery for patellofemoral pain should only be considered after a full course of supervised physiotherapy (minimum 3-6 months) has been completed and has failed. The surgery is indicated only for specific anatomical pathology (elevated TT-TG, patella alta) - not for patellofemoral pain in the absence of clear structural abnormality.
Tibial tubercle transfer (Fulkerson osteotomy) surgically repositions the patellar tendon attachment to correct anatomical malalignment. Performed under general anaesthetic and takes approximately 60-90 minutes.
Tibial tubercle transfer is appropriate only for patients with documented anatomical pathology (TT-TG over 20mm, patella alta) who have failed supervised physiotherapy. Discuss the indication carefully with your surgeon.
Routine pre-operative assessment. Blood thinners must be paused. NSAIDs should be stopped 1 week before surgery.
Weight-bearing is protected for 6-8 weeks after tibial tubercle transfer. Arrange crutches in advance.
Post-operative physiotherapy is essential and should be booked before surgery, ideally starting within 1-2 weeks of the operation.
Smoking significantly impairs bone healing at the osteotomy site and increases the risk of non-union. Stopping smoking before and after surgery improves outcomes.
ℹ️ You will be given a specific arrival time. Do not eat or drink (other than clear water up to 2 hours before) from midnight the night before. Bring your medication list and any documents sent by the hospital.
You will be admitted to the ward or day surgery unit, change into a gown, and be seen by the nursing, anaesthetic, and surgical teams before theatre.
Your surgeon will confirm the procedure, mark the operative side, and you will sign a consent form before going to theatre.
You will meet the anaesthetist in the anaesthetic room. Once anaesthesia is established, the procedure will begin.
After surgery you will wake in the recovery room where nurses monitor your vital signs until you are stable and comfortable.
Most patients having arthroscopic or day-case procedures go home on the day of surgery. Those having joint replacement typically stay 1–2 nights. Before discharge, the team will check your pain is controlled, give you wound care instructions, and confirm your follow-up appointment.
You will be given oral pain relief before discharge. Take it regularly for the first 48 hours rather than waiting until pain is severe.
A nurse will check the wound before you leave and explain how to keep it clean and dry.
You will receive a letter for your GP and details of your next outpatient appointment - usually at 2 weeks for a wound check.
Arrange for a family member or friend to collect you. You must not drive on the day of surgery if you have had a general anaesthetic or sedation.
⚠️ Important: If you develop increasing knee pain, fever, or wound changes after surgery, contact your surgical team promptly. Sudden severe pain after a fall in the first 8 weeks may indicate disruption of the osteotomy and requires urgent assessment.
Avoid getting the wound wet until it is fully healed - usually 10–14 days. Use a waterproof cover or cling film when showering.
Do not wait until pain is severe before taking medication. Regular simple analgesia (paracetamol, ibuprofen if appropriate) is more effective.
This is usually 2 weeks after surgery. Sutures or clips will be removed if used.
Seek urgent advice if you develop increasing redness, warmth, swelling, discharge from the wound, or a temperature above 38°C - these may indicate infection.
60-90 minutes. Hospital stay 1-2 nights.
Bone must heal at the osteotomy site before full weight-bearing. Crutches required for 6-8 weeks.
Progressive weight-bearing and physiotherapy. Cycling and swimming when cleared by your surgeon.
Straight-line jogging and gym-based training. Progression guided by physiotherapy-based functional testing.
Cutting and pivoting sport from 6-12 months once strength and confidence are restored. Metalwork removal is occasionally required later if screws become symptomatic.
Surgery for patellofemoral pain has a variable evidence base. Results are best in patients with clearly defined anatomical pathology (elevated TT-TG, patella alta, lateral patellar instability). Surgery for patellofemoral pain in the absence of clear anatomical pathology has poor outcomes and should be avoided.
Most patients return to driving at 8-10 weeks for the right knee, once weight-bearing is unrestricted and an emergency stop can be performed safely. Left knee surgery in an automatic vehicle may allow earlier return. Confirm with your insurer.
The screws used to fix the tibial tubercle are usually left in place. Around 10-20% of patients find the screw heads prominent or uncomfortable when kneeling, in which case they can be removed as a short day-case procedure once the osteotomy has fully healed (usually after 12 months).
Non-union of the osteotomy occurs in 1-3% of cases. Risk factors include smoking, diabetes, and not following weight-bearing instructions. If non-union occurs, revision surgery with bone grafting may be required.
In patients with clearly defined anatomical pathology (elevated TT-TG, patella alta, lateral maltracking) who have failed comprehensive physiotherapy, tibial tubercle transfer may reduce patellofemoral joint loading and improve patellar tracking, reducing pain.
Under general anaesthetic, through an incision over the tibia, the tibial tubercle (the bony attachment of the patellar tendon) is cut and repositioned - moved medially to reduce the TT-TG distance and/or anteriorised to reduce patellofemoral joint reaction force. The repositioned bone is held with screws. Takes approximately 60-90 minutes.
The most effective treatment for patellofemoral pain. A 3-6 month structured programme targeting quadriceps, VMO, and hip strengthening achieves significant improvement in the majority of patients. Surgery should not be offered before this has been fully tried.
Short-term symptomatic relief to facilitate physiotherapy engagement.
May help if foot pronation is contributing to dynamic valgus.
Load management and activity modification may allow symptoms to settle over time.
Failure of the tibial tubercle to heal in its new position. May require revision surgery.
Wound or bone infection.
The tibial tubercle cut can extend into the tibial shaft.
Screws fixing the tibial tubercle may cause prominence and skin irritation, requiring removal.
Surgery does not guarantee resolution of patellofemoral pain. The evidence base for surgery is less robust than for physiotherapy.
Expected after tibial osteotomy.
The tibial scar may be tender for several months.
Patellofemoral pain resolves or significantly improves with physiotherapy in approximately 70-80% of patients over 6-12 months. Surgery has a limited and less well-evidenced role. In the absence of clear anatomical pathology, surgery for patellofemoral pain has poor outcomes and should not be offered.