Revision Tibial Tubercle Osteotomy for Nonhealing: A Single-center Case Series

The tibial tubercle osteotomy (TTO) is a versatile surgical approach for patellofemoral joint conditions, with nonunion, fracture, and recurrent instability as common indications for revision. This case series describes the management and outcomes of revision TTOs performed for these complications. A retrospective review of 20 patients undergoing revision TTO was conducted. Patients were included if they underwent revision for nonunion, delayed union, or fracture after primary TTO. Data collected included patient demographics, primary and revision TTO details, concurrent procedures, biological adjuncts, fixation methods, and clinical outcomes. Outcomes measured were union rates, time to healing, and subsequent revision. The mean age of the cohort was 26.8 ± 11.7 years, with a mean follow-up of 2.6 ± 2.7 years. Indications for revision were nonunion (70%), fracture (15%), and recurrent instability (15%). Biological augmentation, including bone marrow aspirate concentrate (BMAC), was used in 80% of revisions. Following revision TTO, 65% achieved union at a mean time of 14.6 ± 5.0 weeks, 15% had delayed union (mean time to union 11.9 ± 6.7 weeks), and 15% required a second revision for nonunion, achieving union at a mean time of 15.2 ± 12.7 weeks. Patients with delayed union were older (38 ± 12 years, p = 0.049) and had higher rates of vitamin D deficiency. Revision TTO is effective in addressing nonunion, delayed union, and fractures, with a majority achieving union after revision or re-revision. Strategies such as robust fixation, biological augmentation (e.g., BMAC), and management of comorbidities, including vitamin D deficiency, play a critical role in optimizing outcomes. Further research is needed to standardize protocols and improve union rates in high-risk populations. What are the new findings: This 20-patient case series focuses specifically on revision TTO, reporting granular management and outcomes-65% union after revision, union after all re-revisions, 80% use of biologic augmentation, and an observed association of delayed union with older age and vitamin D deficiency. This adds actionable details on biologic use and fixation escalation and spotlights potentially modifiable risk factors in the revision setting.