Tibial tubercle osteotomy yielded good outcomes for patellofemoral malalignment, damage
According to the published results, tibial tubercle osteotomy for patients with patellofemoral malalignment and chondral disease without instability resulted in positive clinical outcomes and acceptable complication and failure rates.
In December of 2020, Federica Rosso, MD, and colleagues systematically reviewed 18 studies which included 851 patients who underwent 892 tibial tubercle osteotomies (TTOs) with an average follow-up of 49.1 months. Researchers noted indications for TTO were “poorly described” throughout the literature; however, chronic anterior knee pain was a main indication in all studies.
An anteriorization technique was performed in six studies (312 cases); a medialization technique was performed in two studies (41 cases); and an anteromedialization technique was performed in 10 studies (539 cases). TTO was associated with lateral release in 247 cases (27.7%), as noted in seven studies. Despite differing outcome scoring systems, TTO yielded “significant improvements” across the literature, the researchers noted. The average rate of good to excellent results was 78.7%, with a complication rate of 9.9% (reported across 15 studies) and a failure rate of 6.2% (reported across four studies).
While no consensus was reached regarding indications for TTO to treat patellofemoral (PF) chondral disease throughout the literature, Rosso and colleagues concluded TTO yielded positive outcomes in this population.
“TTO to treat PF chondral disease seems to provide good clinical outcomes and acceptable complication/failure rates,” they wrote in the study. “High-quality studies with homogeneous methods are required to precisely determine ideal candidates for TTO, most reliable surgical techniques and outcomes,” they added.
Perspective
Back to TopTibial tubercle osteotomy (TTO) can be a powerful tool to address patellofemoral malalignment in the setting of symptomatic chondral disease. Unloading the patellofemoral joint has been shown to reduce pain and improve function in select patients.
Surgical indications and techniques for TTO continue to evolve. Historically, there is a paucity of outcome studies investigating these patients without concomitant patellofemoral instability. The systematic review by Rosso and colleagues demonstrates good outcomes of TTO with an acceptable complication profile.
Unfortunately, this study poses more questions than answers. It highlights knowledge gaps and deficiencies in our literature. We cannot determine appropriate threshold values (ie, TT-TG) for TTO. We do not have enough information to correlate outcome with size, depth and location of cartilage defects nor exact information on TTO type (ie, AMZ), amount or accuracy of correction. Variation in surgical technique, fixation and rehabilitation are limiting. The review did not include articles with concomitant cartilage restoration (ie, MACI, OCA), except for debridement/drilling, and lateral release was dominant instead of lengthening.
Despite limitations, this systematic review is encouraging and echoes results from Fulkerson’s classic series. We should applaud the authors but also encourage ourselves to improve the quality of our data analysis and outcome reporting to further advance the specialty for our patients.
Perspective
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After 40 years of doing anteromedial TTOs, I concur with the authors’ conclusions. For proper indications in the hands of a skilled, well-trained surgeon, anteromedial TTO using oblique osteotomy is consistently effective and safe for the definitive treatment of patients with intractable pain caused by lateral PF joint overload and arthrosis when medial PF cartilage is intact. Most do well without autologous chondrocyte implantation and complications are uncommon.
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