Combining tibial tubercle osteotomy with medial patellofemoral ligament reconstruction often yields better outcomes in treating patellofemoral instability: a systematic review and meta-analysis of case-control studies

Abstract

Abstract Purpose Tibial tubercle osteotomy (TTO) is often employed for certain patellofemoral instability (PFI) cases, though its indications and effectiveness are not widely accepted. This systematic review gathers recent studies comparing isolated medial patellofemoral ligament reconstruction (iMPFLR) to MPFLR combined with TTO in managing PFI and to offer recommendations for clinicians when selecting TTO. This review proposes that MPFLR combined with TTO is superior to iMPFLR and that the combined procedure does not increase the incidence of postoperative complications. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020), extensive searches were performed on August 20, 2024, across PubMed/Medline, Embase, and Cochrane databases to locate relevant studies. Data on research protocols, participant characteristics (including epidemiological and radiographic features), functional scores, and complications were collected and examined. A meta-analysis was conducted to compare the outcomes between the two surgical techniques. Results This systematic review analyzed 10 studies involving 715 participants, divided into a control group (which underwent iMPFLR) and an experimental group (which underwent MPFLR combined with TTO). In the control group, the incidence of severe trochlear dysplasia before surgery was 68.3% (95% CI [67.3-69.3%]), and the mean preoperative tibial tubercle to trochlear groove distance (TT-TG) was 16.1 mm (95% CI [15.8–16.3]). In the experimental group, both were respectively 79.1% (95% CI [77.5–80.7]) and 20.2 mm (95% CI [20.0-20.4]). Eight studies (80%) reported postoperative Kujala scores, with an average score of 85.1 (95% CI [84.4–85.9]) for the control group and 85.4 (95% CI [84.9–85.9]) for the experimental group (I²=22.7%). Four studies (40%) reported postoperative Lysholm scores, with an average score of 89.4 (95% CI [88.9–89.9]) for the control group and 89.1 (95% CI [89.0-89.3]) for the experimental group (I²=0%). The mean surgical failure rate for the control group was 5.1% (95% CI [4.7-5.6%]), compared to 3.2% (95% CI [3.0-3.4%]) for the experimental group, with an odds ratio (OR) of 2.18 (95% CI [1.05–4.53], I²=0%, p = 0.738). The rate of secondary surgeries in the control group was 1.9% (95% CI [1.6–2.2]), while in the experimental group it was 10.7% (95% CI [9.4–12.1]), with an OR of 0.12 (95% CI [0.03–0.54], I²=63.1%, p = 0.028). Conclusion The combination of MPFLR and TTO for treating PFI yields knee joint function comparable to that achieved with MPFLR alone. The approach does not elevate the failure rate of the surgery or the incidence of other adverse events. However, the combined approach may prolong the postoperative rehabilitation process and typically requires removal of internal fixation devices, resulting in a higher rate of secondary surgeries.

Keywords

• Patellofemoral instability
• Medial patellofemoral ligament
• Tibial tubercle osteotomy
• Treatment
• Meta-analysis