Maquet osteotomy is a knee operation designed to reduce pressure in the patellofemoral joint, which is the joint between the kneecap and the front of the thigh bone. In simple terms, it is a tibial tubercle anteriorization procedure. That means the bony attachment of the patellar tendon at the front of the shinbone is moved forward so that painful pressure behind the kneecap can be reduced [1][2].

In my practice, I usually explain to patients that Maquet osteotomy is not one of the most commonly performed modern knee surgeries, but it remains an important historical and biomechanical concept in patellofemoral surgery. It was originally described to treat persistent anterior knee pain, chondromalacia, and patellofemoral osteoarthritis that did not improve with non-surgical treatment [2][3].

For Bangladeshi patients and families, this topic matters because pain in the front of the knee is very common. It affects stair climbing, rising from the floor, squatting, prayer movements, commuting, and standing for long hours. However, not every patient with kneecap pain is a candidate for this kind of surgery. Careful diagnosis is essential.

What Is Maquet Osteotomy?

Maquet osteotomy is a form of tibial tubercle osteotomy. The principle is to move the tibial tubercle forward, which changes the mechanics of the extensor mechanism and helps reduce compressive force in the patellofemoral joint [2][4].

What is the goal of the procedure?

The main goal is to unload the painful cartilage surfaces behind the kneecap. Maquet proposed that by increasing the angle between the patellar tendon and quadriceps mechanism, patellofemoral pressure could be reduced [2].

This is why the operation was traditionally considered in patients with:

• patellofemoral osteoarthritis
• chondromalacia patella
• persistent anterior knee pain
• loss of function related to patellofemoral overload

Why Pain Behind the Kneecap Happens

The kneecap does not work alone. It moves within the groove of the femur as the knee bends and straightens. If cartilage in this area becomes damaged or overloaded, patients may develop pain in the front of the knee, especially during:

• stair climbing
• squatting
• getting up from the floor
• prolonged sitting with bent knees
• standing up after sitting
• walking uphill or downhill

In Bangladesh, these symptoms can interfere with daily activities in a major way. I often see patients who struggle with stairs in apartment buildings, mosque prayer positions, household work, classroom or office routines, and crowded city commuting. That is why understanding the exact cause of kneecap pain is so important.

Conditions Historically Treated With Maquet Osteotomy

Maquet osteotomy was mainly described for patellofemoral pain caused by pressure overload in the kneecap joint.

Common indications described in the literature

Historical and later follow-up studies describe use of the Maquet principle in:

• patellofemoral osteoarthritis [2][3]
• chondromalacia patella [2][3]
• anterior knee pain resistant to conservative care [3]
• selected patellofemoral dysfunction patterns

One older PubMed study using a modified Maquet principle reported indications such as patellofemoral pain and loss of active function, including patients with chondromalacia, patellofemoral arthritis, patellar dislocation, prior trauma, and previous patellectomy [3].

How the Procedure Works

The basic idea is mechanical unloading. By moving the tibial tubercle anteriorly, the pressure behind the kneecap can be reduced during knee motion [2][4].

Biomechanical reasoning

I usually explain this in a practical way: if the kneecap is being pressed too forcefully against worn cartilage, then changing the line of pull of the patellar tendon can reduce that painful contact. This is the core Maquet concept.

Modern reviews of tibial tubercle osteotomy still recognize Maquet’s anteriorization as one of the foundational unloading procedures for the patellofemoral joint [4][5].

Is Maquet Osteotomy Still Common Today?

No, it is not as commonly used as it once was.

Why it became less popular

Although the original biomechanical idea was sound, the classic Maquet procedure became associated with soft tissue and wound complications, especially because larger degrees of anterior advancement placed pressure under the skin over the tibial tubercle [2][5].

The long-term review of the Maquet III procedure notes that many surgeons became concerned about the healing process and soft tissue complications, leading to modifications and, eventually, reduced popularity of the original technique [2].

What changed in modern practice?

Over time, other tibial tubercle osteotomy techniques evolved, especially:

• straight medialization
• anteromedialization
• distalization in selected cases

AOSSM notes that Maquet’s pure anteriorization was described to offload the patellofemoral articulation in arthritis, but it lost favor because of wound and soft tissue complications, while more modern procedures such as Fulkerson-type anteromedialization became more commonly used [5].

How I Evaluate a Patient With Anterior Knee Pain

In my practice, I do not think about Maquet osteotomy simply because a patient has pain at the front of the knee. The first step is to understand the exact diagnosis.

Questions I focus on

• Where is the pain exactly?
• Is it behind the kneecap or more to one side?
• Is there instability or repeated kneecap dislocation?
• Is the pain mainly during stairs, squatting, prayer, or prolonged sitting?
• Has there been trauma?
• Has proper non-surgical treatment already been tried?

Examination and imaging

Evaluation may include:

• physical examination of patellar tracking
• assessment for crepitus and tenderness
• alignment assessment
• X-rays including patellofemoral views
• MRI when cartilage, maltracking, instability, or associated soft tissue injury is suspected

This is important because front-of-knee pain can come from several different problems, including patellar maltracking, instability, cartilage wear, lateral patellar compression syndrome, tendinopathy, or generalized arthritis. A patient with one diagnosis may benefit from physiotherapy, while another may need realignment surgery, and another may be better treated with arthritis-focused care.