Medial Patellofemoral Ligament Reconstruction With Concomitant Tibial Tubercle Osteotomy

Patellar instability, often associated with medial patellofemoral ligament rupture, is prevalent in adolescents. Risk factors include trochlear dysplasia, patella alta, abnormal patellar tilt, and increased tibial tubercle to trochlear groove (TT-TG) distance.

A variety of surgical options are available for addressing patellar instability, and the selection of each technique should be tailored to the unique pathoanatomy of each patient. Medial patellofemoral ligament reconstruction (MPFLR) is indicated for patients with patellar instability, and tibial tubercle osteotomy (TTO) is indicated for patients with a TT-TG >20 mm.

An anterior midline incision is performed to expose the patella, patellar tendon, and tibial tubercle. Diagnostic arthroscopy is performed to assess patellar engagement and cartilage integrity, followed by the TTO. Three guidewires are placed with 15° of obliquity, to guide a 6-cm osteotomy, from medial to lateral and from proximal to distal. A distal cortical hinge must be left intact. A 15-mm medial resection of the tibial tubercle is performed to avoid protrusion against the skin, which is followed by medialization of the tubercle and fixation with K-wires until dynamic testing ensures proper alignment and definitive fixation is achieved with cannulated headless screws. A lateral retinacular lengthening is performed to balance patellar forces. MPFLR is executed using a semitendinosus allograft. The graft is anchored to the patella and drawn through a surgically created plane to the medial femoral condyle. The femoral tunnel is created under fluoroscopy guidance, and the graft is then passed and secured. Graft tension and patellar mobility are adjusted according to dynamic testing. Once patellar stability is achieved and maintained through range of motion, the graft is then fixed.

Patients can expect improved clinical outcomes with a high return-to-sports rate following both isolated MPFLR and concomitant TTO. The combination of MPFLR + TTO significantly reduces revision rate, compared to isolated MPFLR in patients with increased TT-TG distance, and enhances postoperative patellofemoral tracking.

MPFLR + TTO improves patellofemoral tracking and corrects patellar instability, substantially improving postoperative outcomes compared to MPFLR alone. Patients with patellar instability and an increased TT-TG may be effectively treated with MPFLR + TTO.

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