Revisiting Fulkerson's Original Technique for Tibial Tubercle Transfer: Easing Technical Demand and Improving Versatility  T.J. Ridley, M.D., Michael Baer, M.D., Jeffrey A. Macalena, M.D.  Arthroscopy Techniques  Volume 6, Issue 4, Pages e1211-e1214 (August 2017) DOI: 10.1016/j.eats.2017.04.013 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 (A) Setup for right-sided tibial tubercle osteotomy. Patient is positioned supine on the operating table with the operative knee resting on a radiolucent triangle at approximately 30° of flexion. The surgical field is prepped and draped in standard surgical fashion. The skin is incised in a longitudinal fashion directly over the tibial tubercle, initiated 1 cm proximal and finishing 6 cm distal to the tibial tubercle. Patient supine, right leg, head to the left of the image. (B) An electrocautery device is used to mark the medial and lateral fascial borders of the patellar tendon, with plans for an osteotomy approximately 6 cm in length. Patient supine, right leg, head to the left of the image. (C) Three osteotomy guide pins are placed colinearly in a medial to lateral direction at the desired osteotomy angle, and the angle of the proposed osteotomy can now be visualized. Patient supine, right leg, head to the left of the image. (TT, tibial tubercle.) Arthroscopy Techniques 2017 6, e1211-e1214DOI: (10.1016/j.eats.2017.04.013) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 (A) The near medial cortex is then scored with an oscillating saw along the previously set guide pins, and the osteotomy is completed in a medial to lateral fashion. Patient supine, right leg, head to the top of the image. (B) An osteotome is used to complete the osteotomy with manual elevation of the tuberosity fragment. Here, it is the surgeon's choice to carry the osteotomy distally through the periosteum, or to leave this portion intact, allowing for a distal cortical hinge. Patient supine, right leg, head to the top of the image. (TT, tibial tubercle.) Arthroscopy Techniques 2017 6, e1211-e1214DOI: (10.1016/j.eats.2017.04.013) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 (A) The tuberosity fragment is then replaced flush within the tibial bed, medially translating and distalizing the fragment. Patient supine, right leg, head to the top of the image. (B) Definitive fixation of the translated tubercle is accomplished with a 3.5-mm fully threaded cortical screw on compression, using a countersink method to prevent hardware prominence. Patient supine, right leg, head to the right of the image. (TT, tibial tubercle.) Arthroscopy Techniques 2017 6, e1211-e1214DOI: (10.1016/j.eats.2017.04.013) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 The angle of osteotomy and amount of translation can be calculated using right-triangle trigonometry. Axial illustration of left tibia. (TT, tibial tubercle.) Arthroscopy Techniques 2017 6, e1211-e1214DOI: (10.1016/j.eats.2017.04.013) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions