Nonunion after a tibial shaft fracture complicating tibial tubercule osteotomy

Tibial shaft fracture after tibial tubercle osteotomy in total knee replacement is a rare complication. We report on a 67-year-old man who had a knee revision arthroplasty in which a long tubercle osteotomy was performed to facilitate exposure. Three weeks after surgery, he presented with a transverse shaft fracture, which became a nonunion requiring surgical management. This shaft nonunion and its solution after tibial tubercle osteotomy is discussed as well as relevant literature.     

Distal realignment of the patellar tendon to correct abnormal patellar tracking

Between January 1980 and January 1994, 31 knees required distal realignment of the extensor mechanism to treat lateral patellar subluxation that could not be corrected with lateral patellar release and vastus medialis advancement during total knee arthroplasty. Fifteen had a preoperative valgus angle of more than 12 degrees, and 16 were undergoing revision total knee arthroplasty. Ten knees had a modified Roux-Goldthwait procedure, 18 had medial tibial tubercle transfer, and three had medial transfer of the medial 1/2 of the patellar tendon. The length of followup ranged from 2 to 16 years. No late patellar subluxations or dislocations have occurred in any of these cases. Three cases of medial tibial tubercle transfer had hematomas develop, with two requiring surgical evacuation; one of these developed a late infection. No fractures or displacements of the tubercle fragment have occurred. No significant patellar complications have occurred in those patients who underwent the modified Roux-Goldthwait procedure or the medial transfer of the medial 1/2 of the patellar tendon. One year after surgery, the mean knee flexion was 113 degrees, four knees had a flexion contracture of 5 degrees, and none had a quadriceps lag.     

Contents of total and protein-bound carbohydrates are low in leukemic leukocytes from patients with acute myelogenous leukemia

The successful approach to the failed knee with bone deficiency is dependent upon thorough planning prior to surgery in order to have the resources available in terms of adequate bone allograft and suitable revision implants. The approximate size of bone stock deficiency can be calculated from preoperative radiographs and similarly ligamentous incompetence can often be diagnosed clinically prior to surgery. Smaller defects of up to 1 to 1.5 cm in depth and localized in the main to a single side of the tibial plateau or to a single femoral condyle can be dealt with using smaller grafts that may be local autograft or allograft, or modular wedges. Larger tibial defects can be compensated for using conventional revision systems by thicker polyethylene and augmented baseplates, but once the flexion-extension gap reaches approximately 40 mm this is no longer possible and structural graft or customized componentry becomes necessary. Femoral defects larger than about 1 cm that cannot be made up by augments necessitate grafting. The need to use a large proximal tibial allograft also may dictate the operative approach used to expose the joint, especially in the situation of a multiply-operated tight knee. In such cases the use of a quadriceps turndown may be more advisable than the use of a tibial tubercle osteotomy as the osteotomy may well not have an adequate bed to heal to following the reconstruction. Several series have reported cases of patellar tendon avulsion and the clinical results following this complication usually are not satisfactory. Preoperatively it is important to identify, if possible, the case that is likely to require a more extended approach because of a tight soft tissue envelope. The reports of results of series of revision total knee arthroplasty in the setting of significant bone loss are at present confined to short-term followup. The clinical results of these series are satisfactory at this early point in time, but decision regarding the durability of reconstructions requiring major structural allografting awaits longer-term study. Of concern is the devastating complication of infection following such revision surgery, the risk of which is amplified in the setting of prior infection. In addition, the long-term viability of major structural grafts in the setting of loading is uncertain as the risk of graft collapse in the process of incorporation is not known. Notwithstanding these concerns, major grafting is sometimes the only recourse to achieve satisfactory revision of a failed arthroplasty. The use of such major grafts is therefore cautiously supported and because of the risks inherent in such surgery we believe that such surgery should be carried out in the setting of specialist interest units.     

Management of late induced abortions in France

OBJECTIVE: To evaluate the clinical results of comminuted patella fracture fixation after an extensile surgical approach by using a tibial tuberosity osteotomy. DESIGN: Prospective, clinical. PATIENTS: Six knees with displaced comminuted patella fractures had stable internal fixation after an osteotomy of the tibial tubercle. All had immediate postoperative continuous knee motion and were followed for an average of thirty-one months (minimum of eighteen months). OUTCOME MEASURES: Time to clinical and radiographic union, Hospital for Special Surgery (HSS) Knee Scores and comparisons with literature cohort studies. RESULTS: Clinical union of the osteotomy occurred at an average of eight weeks (range 6 to 12 weeks) and of the patella fractures at an average of eleven weeks (range 8 to 21 weeks). There was no radiographic evidence of osteotomy displacement, fracture implant loosening, migration, or failure. All patients had clinical residua, which included loss of motion, thigh muscle atrophy, and barometric complaints. HSS Knee Scores averaged 75 points with four good, one fair, and one poor result. These results were comparable to those of previously published reports of ablative surgery for this type of fracture. CONCLUSION: Comminuted patella fractures are severe injuries that usually result in some lingering morbidity. Internal fixation preserves bone stock, which facilitates future reconstructive procedures. The described tibial tuberosity osteotomy, patella eversion technique of fracture exposure improved visualization and reduction of the articular surface. The osteotomy healed in all cases and did not adversely affect the clinical results.     

Total knee replacement after failed tibial osteotomy: results of a matched-pair study

Sixty-three total knee replacements were performed after a failed tibial osteotomy. The goal of this study was to compare the perioperative problems and the outcome of this group of patients (study group) to a group of patients with primary arthroplasties matched for age, gender, length of follow-up, weight, and preoperative Charnley class. Operative problems were more frequently encountered in the study group, with 7 tibial tubercle elevations and 15 lateral retinaculum releases needed, whereas lateral retinaculum release was necessary for only 1 knee in the control group. Outcome was assessed using both the International Knee Society (IKS) scoring system and Hospital for Special Surgery (HSS) knee score. The follow-up period averaged 4.6 years. The IKS score of the control group was significantly higher, averaging 80.9 +/- 13.8, whereas it was 74.4 +/- 14.8 for the study group (P = .0001). Among the parameters included in the knee score, only pain was significantly different with the control group (P = .03). The IKS function score and the HSS score were not statistically different. Conversion of a failed tibial osteotomy is a technically demanding procedure. Careful preoperative planning is needed. Results, especially on pain, appeared to be inferior to those for primary arthroplasties.     

Effect of medial displacement of the tibial tubercle on patellar position after rotational malposition of the femoral component in total knee arthroplasty

A large Q angle induced by technical error such as an internally rotated femoral component causes patellar failure after total knee arthroplasty. The effect of medial displacement of the tibial tubercle to decrease the Q angle for patellar tracking was studied by evaluating the patellar position relative to the patellar groove on the femoral component in cadaver specimens. A 5 degrees internally rotated femoral component caused the patella to shift medially about 5 mm, and also caused the tibia to rotate internally about 3 degrees at full extension. With a 5 degrees externally rotated femoral component, normal patellar tracking occurred. The distance of medial displacement was determined so that the patellar tendon was parallel to the longitudinal axis of the tibia at full extension. This allowed the quadriceps tendon, the patella, and the patellar tendon to form a straight line. The average distance of medial transposition of the tibial tubercle was 9.32 mm. Medialization of the tibial tubercle caused the patella to shift about 2 mm medially from the patellar groove. The transfer also caused an external rotation of the tibia (2 degrees-5 degrees). Medial transfer of the tibial tubercle changes patellar kinematics and corrects the tendency toward lateral patellar dislocation caused by internally rotating the femoral component; however, it also creates minor patellar and tibial kinematic changes that may have a clinical effect.     

Patella height after high tibial osteotomy with internal fixation and early motion

The purpose of this study was to compare the incidence of patella infera in patients after high tibial osteotomy treated with either postoperative immobilization or internal fixation and early range of motion. A retrospective review of 98 patients with high tibial osteotomy was done at the authors' institution. Thirty-three patients who had secondary procedures such as concomitant ligamentous reconstruction with early motion were excluded. Therefore, 69 knees in 65 patients remained in the study cohort. Group A consisted of 32 patients (34 knees) treated with postoperative immobilization, whereas Group B included 33 patients (35 knees) treated with internal fixation and early motion. The preoperative and postoperative Insall-Salvati index, Blackburne-Peel index, and angular alignment were determined for each group. Between Groups A and B, the differences in the Insall-Salvati index and the Blackburne-Peel index were statistically significant, although the difference in angular correction was not significant. With rigid fixation and early motion the Insall-Salvati index showed that there was less postoperative shortening of the patellar tendon. The relationship of the patella to the remainder of the knee was affected less adversely as evidenced by the Blackburne-Peel index. High tibial osteotomy with internal fixation and early range of motion should result in a better knee and ease the subsequent performance of a total knee arthroplasty.     

Intraoperative computer-assisted measurement of stimulation threshold of the common peroneal nerve in osteotomy of the head of the tibia

Using a computer-assisted threshold hunting paradigm the motoric threshold of the common peroneal nerve was monitored in 18 patients during a high tibial osteotomy (HTO). The exposed nerve (lateral approach) was stimulated proximal to the osteotomy area and the surface EMG of the M. tibialis anterior was used to guide a threshold hunting device. Motoric threshold as a sensitive indicator of nerve function was found to be almost unaffected by several surgical steps of HTO. Only forceful rotation of a subperiostal Hohmann device during high peroneal osteotomy evoked a slight threshold shift that was fully reversible with device repositioning. The tourniquet, however, affected the threshold significantly. In 10 of the 18 patients the nerve became completely inexcitable after an average time of 59 min. The inexcitability was reversible after opening of the tourniquet. On the other hand, the eight patients maintaining an excitability throughout the entire ischemic period had tourniquet times that did not exceed 60 min. There are several factors that may be responsible for the observed inexcitability after long ischemic periods and we conclude that tourniquet time minimization appears appropriate to avoid neurological deficits during a high tibial osteotomy.     

External tibial torsion: an underrecognized cause of recurrent patellar dislocation

Seventeen patients (18 knees) with recurrent patellar dislocation were identified with increased quadriceps angles secondary to excessive isolated external tibial torsion. Traditional realignment procedures attempted in these knees were unsuccessful because of failure to align the biomechanical axis of the extensor mechanism. Derotational osteotomies of the tibia just proximal to the patella tendon insertion were used to reduce the quadriceps angle to within normal limits to improve the biomechanics of the extensor mechanism. Seventeen (94%) knees were available for clinical and subjective followup at an average of 25 months (range, 1-3.2 years). Overall, 13 of the 17 knees were graded as good to excellent (76%). Five of the 17 patients also had well established anterior knee pain in addition to recurrent dislocation and were treated with a combined derotational and Maquet type osteotomy, with 4 patients obtaining a good to excellent result. Knees that subjectively and functionally demonstrated less painful symptoms preoperatively were associated with excellent results. Poor outcomes were associated with knees that were operated on multiple times.     

Malrotation causing patellofemoral complications after total knee arthroplasty

Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements without patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on computed tomography scans to measure quantitatively rotational alignment of the femoral and tibial components. The group with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation. This excessive combined internal rotation was directly proportional to the severity of the patellofemoral complication. Small amounts of combined internal rotation (1 degree-4 degrees) correlated with lateral tracking and patellar tilting. Moderate combined internal rotation (3 degrees-8 degrees) correlated with patellar subluxation. Large amounts of combined internal rotational (7 degrees-17 degrees) correlated with early patellar dislocation or late patellar prosthesis failure. The control group was in combined external rotation (10 degrees-0 degree). The direct correlation of combined (femoral and tibial) internal component rotation to the severity of the patellofemoral complication suggests that internal component rotation may be the predominant cause of patellofemoral complications in patients with normal axial alignment. The epicondylar axis and tibial tubercle are reproducible landmarks which are visible on computed tomography scans and can be used intraoperatively. Using this computed tomography study can determine wether rotational malalignment is present and thus, whether revision of one or both components may be indicated.     

Shift and tilt of the bony patella in total knee replacement

Resurfacing the patella or not in total knee arthroplasty is generally still a quite controversial topic. In that context we felt a necessity to get more informations about the natural history of a non resurfaced patella in the prosthetic surrounding than only in comparison with a replaced patella. By the fact that we haven't been replacing patellae apart from special cases since up to five years, we have available a patient selection on which this question can be studied. Thirty primary total knee replacements with documented 2 year's follow up have been investigated by calculation of the radiological patellar shift and tilt relative to the natural groove on preoperative X-rays and to the prosthetic groove in the postoperative evolution. These results were matched with the range of motion obtained after two years and with persisting pain. Only mobile polyethylene inlays had been used. With regard to the patella no difference was found for one single complete tibial tray or two separately implanted unicompartimental tibial trays. As a rule an adaptation of the bony patellar contour to the prosthetic groove was observed with an increased density of the bony contact area with or without a fibrous interstitial layer. Based on their clinical follow up examination seven patients had to be adjointed to a "residual problem group", as they presented persisting pain (3) or a poor range of motion of 90/0/0 degree of flexion/extension or less. Only in this group we found cases with a postoperative shift over 5 mm (2) and a postoperative tilt over 15 degrees (3). Inside this group, also with a significant difference from the group without residual problems, there was furthermore a correlation between persisting pain and an important preoperative tilt and between a diminished range of motion and a considerable preoperative shift. It has to be pointed out that even the cases without long severe malposition before the arthroplasty but with unsatisfactory realignement referring to the patellar tilt (7 degrees-15 degrees) have been found pain free at the last follow up. One patient with a severe secondary increase of disalignment (16 mm/139 degrees) due to an aseptic tibial loosening represents a particular case. After corrective revision of the tibial implants this patient also got again a complete pain relief and a good range of motion without any surgical measure to the patella and inspite of an evident residual tilt. Thus we have to conclude that it is justified to take important pains with the realignment to obtain a residual patellar shift of less than 5 mm. Apart from usual operative steps during the implantation to favour a good patellar tracking, e.g. a high quadriceps release or a medially transposed refixation of the detached tibial tubercle can get necessary. On the other hand a residual tilt up to 15 degrees is well tolerated, as the unresurfaced patella presents an astonishing ability of adaptation to the prosthetic groove by remodelling of the bony contour and structure. Nevertheless in the included cases of severe preoperative malposition, in which we didn't replace the patella because of a good intraoperative bone quality, we had to put up with an increased incidence of late problems even with normalized patellar tracking. In such cases an extended indication to a patellar resurfacing may be considered.     

Revision knee arthroplasty with patella replacement versus bony shell

A study was undertaken to assess the clinical results of revision total knee arthroplasty in which an unresurfaced bony shell was left after removing a patellar component versus those in which a patellar component was implanted. Followup was obtained in 123 of 130 consecutive revision total knee replacements (94%) from three centers. In 21 knees a shell of patellar bone was left and 92 knees had a patellar component in place. Ten patients had a patellectomy and were excluded from consideration. The group with the bony shell had a lower postoperative knee score but the preoperative Knee Society clinical score was significantly lower as well in this group of patients. Compared with the group of patients with the patellar component in place, the group of patients with knees left with a bony shell had a significantly higher percentage of patients who had difficulty using stairs, a higher percentage of patients who were not satisfied with their surgery, and a higher percentage of patients who rated their surgery as unsuccessful in returning them to normal daily activities. When a patellar component was not able to be implanted in revision total knee arthroplasty, a lower quality result was observed.     

Binding of mutated Ras- and p53-derived peptides to HLA-DR molecules

We investigated retrospectively 132 cases of open wedge high tibial osteotomy using an external fixation device, concentrating on the rate of neurological complications. One group of patients underwent surgery according to the conventional technique (n = 89). The rate of transient neurological complications was 15.7%; 7 months after surgery the rate of persistent deficits was 12.4%. For the second group (n = 43) a modified surgical technique was used that lowered the complication rate significantly (transient deficits 14%, persistent deficits 4.7%). In the modified technique the osteotomy is not performed in the conventional way using an oscillating saw but through consecutive drill holes of increasing diameter followed by osteoclasis. The lower complication rate in the second group is mainly due to the less extensive approach that leads to a smaller number of postoperative tibialis anterior syndromes (type B lesion). No differences were found with type C lesions (extension deficit of D1). No complete peroneal nerve palsy (type A) occurred in either group. We conclude that the reduction of neurological complications in group 2 is related to the less extensive approach of the proposed technique.     

Revision total knee arthroplasty after failed unicompartmental knee arthroplasty or high tibial osteotomy

A retrospective matched-pair comparative analysis was done between 30 total knee arthroplasties following failed high tibial osteotomies and 30 total knee arthroplasties following failed unicompartmental knee arthroplasties. The groups were matched according to age, gender, type of prosthesis, primary disease, and length of followup. A minimum followup of 2 years was required for inclusion in the study, and the average followup was 3.8 years (range, 2-9 years). The Knee Society Knee Score for the high tibial osteotomy group was significantly higher than that for the unicompartmental arthroplasty group. More osseous reconstructions were required in the unicompartmental revisions. Difficulty with exposure was not significantly greater in the osteotomy group. Rates of component loosening were not significantly different between the groups. A failed unicompartmental knee arthroplasty and a failed high tibial osteotomy can be revised successfully to a total knee arthroplasty. The results confirm that revisions after unicondylar arthroplasty and high tibial osteotomy are technically demanding. In this series, the results of total knee arthroplasty following unicompartmental knee arthroplasty approached but did not equal those obtained after high tibial osteotomy.     

Closed intramedullary femoral osteotomy. Shortening and derotation procedures

Closed osteotomy and nailing were performed on 37 patients for leg-length inequality or rotational deformities. Shortening operations were performed in 31 patients, derotation in six. Preoperatively, the leg-length discrepancy ranged from 2 to 6.6 cm. All femoral shortenings resulted in correction to less than 1 cm. Preoperatively, rotational deformities averaged 58 degrees; all were corrected to within 5 degrees of normal. Follow-up observation averaged 3.3 years. There were no nonunions or infections. All patients regained preoperative joint range of motion (ROM). Thirteen patients were Cybex tested one year or more postoperatively; all had quadriceps and hamstring strength equal to or greater than the contralateral leg, except for two patients who had suffered additional trauma to the shortened femur. Closed femoral osteotomy is an effective, safe, and reproducible means to obtain lower limb length correction in patients with leg-length inequality or rotational abnormality.     

Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fascio-fat graft

We present the results of a new mobilization procedure for the treatment of a congenital proximal radioulnar synostosis in seven patients. The operative procedure included separation of the synostosis and placement of a free vascularized fascio-fat graft to prevent recurrent ankylosis. The average age at the time of the operation was eight years and two months (range, six years and four months to eleven years and ten months). All of the patients were boys who had no other congenital anomalies. The radial head was dislocated in all seven patients (anteriorly in two and posteriorly in five). The final four index operations included an osteotomy of the radius in order to reduce the dislocated radial head. The average duration of follow-up was three years and eight months (range, two years and four months to four years and five months). Preoperatively, the patients had had difficulty with holding a bowl of soup and accepting objects, such as coins, into the palm. Postoperatively, they were able to perform these activities. None of the patients had recurrent ankylosis or loss of the flap. The average supination was 26 degrees (range, 10 to 45 degrees), and the average pronation was 45 degrees (range, 10 to 80 degrees). The four patients who had had an osteotomy of the radius in addition to the index procedure did not have a dislocation of the radial head and had an average arc of motion of 83 degrees of pronation and supination. The three patients who had not had an osteotomy had a dislocation of the radial head and an average arc of motion of 40 degrees after the index procedure. These findings demonstrate that separation of a congenital radioulnar synostosis with a vascularized fascio-fat graft and osteotomy of the radius can achieve pronation and supination of the forearm.     

Radiologic and histologic analysis of morselized allograft in revision total knee replacement

Morselized cancellous allograft was used to fill large femoral and/or tibial defects in 63 patients (63 knees) who had revision surgery for failed arthroplasty between September 1988 and January 1993. Firm seating of the components on a rim of viable bone and rigid fixation with a medullary stem were achieved in all cases. One patient was lost to followup, leaving 62 patients with standard radiographic evaluation at 1 month, 3 months, and yearly intervals postoperatively. Fourteen patients required reoperation between 3 weeks and 37 months after revision surgery for loosening (two patients), wound avulsion (one patient), wound hematoma (two patients), painful wires (four patients), patellar tendon avulsion from the tibial tubercle (two patients), patellar subluxation (one patient), or late onset instability (two patients). A biopsy specimen was taken from the central portion of the allograft in each case. Evidence of healing, bone maturation, and formation of trabeculae was seen in all allografted areas visible on radiograph at 1 year after surgery. No sign of significant bone graft loss had occurred in any case. Likewise, all biopsy specimens, including the 3-week specimen, showed evidence of active new bone formation in the allografted area. Active bone formation was found in and around the allograft pieces, and new osteoid formed directly on dead allograft trabeculae. Vascular stroma was present between the bone fragments deep in the allograft mass. Older biopsy specimens evidenced progressive maturation, and evidence of active osteoclastic activity was absent by 18 months after surgery. All patients but one had significant improvement in their pain score as compared with their preoperative status. Although the complication rate was high (22%), all but one patient achieved lasting fixation to bone, adequate ligament balancing, good range of motion, and minimal to mild pain. Two patients required revision surgery. Both had greatly improved bone stock so that new implants could be applied with minor additional grafting. This method of bone stock reconstitution appears to be reliable when used in conjunction with firm rim seating and rigid intramedullary stem fixation.     

Conservatively managed tibial shaft fractures in Nottingham, UK: are pain, osteoarthritis, and disability long-term complications?

OBJECTIVES: To investigate longterm pain and disability subsequent to a tibial shaft fracture treated conservatively. DESIGN AND SETTING: Subjects who had sustained a tibial shaft fracture more than 27 years ago were compared with those who had not. SUBJECTS: 572 fracture patients (identified from the records of the plaster room) aged over 16 at the time of injury were contracted and were compared with 2285 randomly selected subjects matched for age, sex, and general practice. MAIN OUTCOME MEASURES: Self reported knee pain; self reported GP's diagnosis of osteoarthritis; ability to climb stairs, walk 100 yards, to bend, kneel, or stoop; and SF-36 physical functioning score. RESULTS: Subjects were reviewed between 27 and 41 years after tibial shaft fracture (mean 35 years). Fracture patients were more likely to suffer chronic knee pain (odds ratio 1.23; 95% confidence interval (CI) 1.00, 1.51) and report being given a diagnosis of osteoarthritis by their GP (odds ratio 1.46; 95% CI 1.08, 1.97). The ability to climb stairs, walk 100 yards, and bend, kneel, or stoop was less in the fracture group than the other subjects. The SF-36 physical function score was significantly lower in the fracture group. CONCLUSIONS: More than 27 years after a tibial shaft fracture, subjects have more knee pain than the rest of the population. They also have greater difficulty performing everyday physical activities. The excess morbidity may be due to injury factors or treatment factors, and further research is needed to investigate this important association further.     

Apoptosis of tubular epithelial cells in familial juvenile gouty nephropathy

Chronic ruptures of the patellar tendon are uncommon injuries. They are technically difficult to repair because of scar formation, poor quality of the remaining tendon, and quadriceps muscle atrophy and contracture. We report the reconstruction of a chronic patellar tendon rupture with an interesting complication, a tibial stress fracture. The reconstruction was performed 3 months after the injury using an Achilles tendon-bone allograft and reinforcing suprapatellar wire. At 2 weeks postoperatively, the patient had attained full extension and 90 degrees of flexion. Ten months after the index procedure, the patient had range of motion 0 degrees to 120 degrees and was diagnosed with a healing tibial stress fracture. At 17 months postoperatively, the patient had attained full extension, 120 degrees of flexion, and 85% quadriceps strength. The preoperative goals of attaining full range of motion, improving quadriceps strength, obtaining anatomic patellar alignment, and restoring function were obtained despite the complication of a tibial stress fracture. Although this reconstructive procedure is technically demanding, with potential complications, the functional results obtained can be excellent.