Fulkerson Type Osteotomy for Knee Conditions
The Fulkerson osteotomy is an effective surgical option for patients with patellofemoral malalignment and chondromalacia patellae who have failed conservative management, with studies showing 72-85% good to excellent results in properly selected patients. 1, 2
Patient Selection and Indications
Primary Indications
- Chronic patellofemoral malalignment with:
- Anterior knee pain unresponsive to conservative treatment
- Chondromalacia patellae (Outerbridge type III-IV)
- Lateral patellar tilt or subluxation
- Pain particularly in lateral and distal regions of patella
Preoperative Assessment
- Imaging evaluation:
- Patellofemoral congruence angle
- Lateral patellofemoral angle
- Patellofemoral index
- CT scan to determine malalignment pattern (lateral tilt, lateral subluxation, or both)
- Arthroscopic examination to confirm chondromalacia severity
Treatment Algorithm
Step 1: Conservative Management (Must be attempted first)
- Quadriceps strengthening exercises 3
- Weight reduction if applicable 3
- Pain management with NSAIDs or topical treatments 4
- Activity modification to reduce load on damaged compartments 4
Step 2: Surgical Intervention (When conservative measures fail)
- Fulkerson osteotomy (anteromedial tibial tubercle transfer)
- Anteriorization of 7-15mm 2
- Consider advancement of vastus medialis oblique muscle in selected cases
Surgical Outcomes
- Improvement in Kujala knee score from 39.2 to 57.7 (p<0.001) 1
- Reduction in visual analogue pain score from 7.8 to 5.0 1
- Overall patient satisfaction with good or excellent results in 72% 1
- Significant improvement in pain and instability scores 2
Prognostic Factors
- Patients with lowest pre-operative Kujala scores benefit most 1
- Younger patients show better outcomes than older patients 1
- Outcome appears independent of the grade of chondromalacia 1
Rehabilitation Considerations
- Critical warning: Aggressive rehabilitation in early postoperative period must be avoided 5
- Weight-bearing should be restricted for approximately 10-12 weeks 5
- High-impact activities (jogging, sports) should be avoided for 9-12 months to prevent proximal tibial fractures 5
- Regular radiographic assessment to confirm bony healing before advancing activity
Potential Complications
- Tibial tubercle avulsion 2
- Deep vein thrombosis 2
- Knee flexion contractures 2
- Proximal tibial fracture (can occur even 6 months post-surgery) 5
- Screw removal may be required in some cases 1
Alternative Surgical Options
- For patients with tricompartmental disease, total knee arthroplasty may be more appropriate 4
- For medial compartment osteoarthritis, high tibial osteotomy or unicompartmental knee arthroplasty may be considered 3, 6
- The American Academy of Orthopaedic Surgeons notes that realignment osteotomy is an option in active patients with symptomatic unicompartmental OA with malalignment 3
The Fulkerson osteotomy represents an important joint-preserving option for patients with patellofemoral issues, particularly in younger, active individuals who are not yet candidates for arthroplasty. Careful patient selection and appropriate postoperative rehabilitation are essential for optimal outcomes.