Tibial Tubercle Osteotomy With Concomitant Medial Patellofemoral Ligament Reconstruction

Abstract

Background: Patellofemoral anatomy allows for substantial freedom of motion. Medial patellofemoral ligament (MPFL) tears occur in up to 96% of lateral patellar dislocations. Risk factors for subsequent instability include maltracking and increased tibial tubercle to trochlear groove (TT-TG) distance. Indication: Medial patellofemoral ligament reconstruction (MPFLR) with concurrent tibial tubercle osteotomy (TTO) is indicated in patients with recurrent dislocation or unresolved apprehension. Concurrent TTO should be considered for TT-TGs 15-20 mm depending on overall clinical picture and risk factors. We strongly consider TTO for TT-TGs ≥20 mm and for revision procedures. Technique Description: Following diagnostic arthroscopy, a midline incision is made from the inferior patellar pole to 3 cm beyond the tibial tubercle. The anterior compartment is incised and retracted laterally. An osteotomy guide is affixed to the tibia and an osteotomy cut is made with a saw, leaving a small bridge of periosteum distally. The osteotomy is competed proximally with osteotomes, then medialized and held in place with two 4.5-mm screws. An incision is made on the superomedial patella and two 0.045 inch guidewires are placed at the MPFL insertion and overdrilled with a 3.5-mm drill. A 22-cm semitendinosus allograft is prepared and fixed to the patella using two 3.5-mm anchors. An incision is made over the medial epicondyle and a 2.4-mm beath pin is placed at Schöttle point. Isometry is confirmed and the pin is overdrilled with a 6-mm reamer. The allograft is passed just superficial to capsule from the peripatellar incision to the medial incision, docked into the femur, and secured with a 6-mm interference screw at 30° of flexion after confirmation of appropriate graft length. Results: Studies have demonstrated improved outcomes for patients undergoing MPFLR + TTO compared with isolated MPFL in the setting of maltracking and increased TT-TG distance. In addition, a recent meta-analysis demonstrated no negative effect of concurrent TTO on return to sport timeline. Discussion/Conclusion: MPFLR with concurrent TTO is effective, with surgical correction of underlying maltracking and satisfactory return to sport. Consideration to MPFL + TTO should be given to patients with recurrent instability and pathologically increased TT-TG. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.