Reasons for and Complications Following Revision Tibial Tubercle Osteotomy

Overview

Journal Orthop J Sports Med

Specialty Orthopedics

Date 2025 Feb 18

PMID 39963265

Authors

Nathan H Varady

Tyler J Uppstrom

Aakash Shah

Morgan Rizy

Ava G Neijna

Andreas H Gomoll

Sabrina M Strickland

Affiliations

Soon will be listed here.

Abstract

Background: While tibial tubercle osteotomy (TTO) is a highly effective treatment for patellofemoral malalignment, some patients may have recurrent symptoms after surgery. To date, there are little data on revision TTO (rTTO) and its outcomes.

Purpose: To evaluate the (1) reasons for and (2) complications following rTTO.

Study Design: Case series; Level of evidence, 4.

Methods: This was a retrospective review of patients who underwent rTTO from a single high-volume patellofemoral surgeon between 2016 and 2023. All included patients had a minimum of 3 months of follow-up data. Demographic characteristics, indications for primary and revision surgery, operative characteristics, concomitant procedures, range of motion at 6 and 12 weeks postoperatively, radiographic data, and complications were collected.

Results: There were 16 knees (14 patients) that underwent rTTO, including 10 (63%) for persistent malignment (all of which had chondral damage requiring concomitant intervention) and 6 (38%) for fracture/nonunion. The knees undergoing rTTO for malalignment were 90% female, compared with 33% female for fracture/nonunion ( = .04). For persistent malalignment rTTO, the only complication (10% [1/10]) was arthrofibrosis (0°-65° at 6 weeks postoperatively), requiring arthroscopic lysis of adhesions (0°-140° at 12 weeks postoperatively). Within the follow-up available (median, 2.2 years; range, 9 months-5.3 years), there were no cases of new or recurrent patellar instability after rTTO. Similarly, at a median follow-up of 1.2 years (range, 4 months-3.0 years), all 6 knees that underwent rTTO for fracture/nonunion achieved union, with delayed union requiring percutaneous bone marrow grafting at 4 months postoperatively being the only complication in this cohort.

Conclusion: Patients who underwent rTTO demonstrated low complication rates and high union rates in this study. There was a high prevalence of chondral damage requiring concomitant intervention among patients undergoing rTTO for persistent malalignment. While rTTO is a relatively rare procedure, these data suggest that it can be a safe and effective option for patients with recurrent symptoms or fracture/nonunion after primary TTO.

References

Li Z, Garra S, Eskenazi J, Montgomery Jr S, Triana J, Hughes A . Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2024; 32(2):371-380. DOI: 10.1002/ksa.12051. View

Ryan P, Ross B, Stamm M, Sherman W, Heard W, Mulcahey M . Concomitant Tibial Tubercle Osteotomy Reduces the Risk of Revision Surgery After Medial Patellofemoral Ligament Reconstruction for the Treatment of Patellar Instability. Arthroscopy. 2023; 39(9):2037-2045.e1. DOI: 10.1016/j.arthro.2023.02.006. View

Uppstrom T, Cash B, Jahandar A, Fletcher C, Nguyen J, Maher S . Proximal bone block with distal screw trajectory improves mechanical stability during distalization tibial tubercle osteotomy. Knee Surg Sports Traumatol Arthrosc. 2023; 31(10):4239-4245. DOI: 10.1007/s00167-023-07467-z. View

Erickson B, Nguyen J, Gasik K, Gruber S, Brady J, Shubin Stein B . Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Regardless of Tibial Tubercle-Trochlear Groove Distance and Patellar Height: Outcomes at 1 and 2 Years. Am J Sports Med. 2019; 47(6):1331-1337. DOI: 10.1177/0363546519835800. View

Varady N, Feroe A, Fontana M, Chen A . Causal Language in Observational Orthopaedic Research. J Bone Joint Surg Am. 2021; 103(19):e76. DOI: 10.2106/JBJS.20.01921. View

Payne J, Rimmke N, Schmitt L, Flanigan D, Magnussen R . The Incidence of Complications of Tibial Tubercle Osteotomy: A Systematic Review. Arthroscopy. 2015; 31(9):1819-25. DOI: 10.1016/j.arthro.2015.03.028. View

Palhares G, Hinkley P, Rizy M, Fletcher C, Gomoll A, Strickland S . Tibial Tubercle Osteotomy With Distalization for the Treatment of Patella Alta. Arthrosc Tech. 2023; 12(5):e609-e614. PMC: 10265199. DOI: 10.1016/j.eats.2022.12.015. View

Klinge S, Fulkerson J . Fifteen-Year Minimum Follow-Up of Anteromedial Tibial Tubercle Transfer for Lateral and/or Distal Patellofemoral Arthrosis. Arthroscopy. 2019; 35(7):2146-2151. DOI: 10.1016/j.arthro.2019.02.030. View

Shah A, Uppstrom T, Rizy M, Gomoll A, Strickland S . Incidence of Complications After Tibial Tubercle Osteotomy and Tibial Tubercle Osteotomy With Distalization. Am J Sports Med. 2024; 52(5):1274-1281. DOI: 10.1177/03635465241235883. View

10.

Fithian D, Paxton E, Stone M, Silva P, Davis D, Elias D . Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004; 32(5):1114-21. DOI: 10.1177/0363546503260788. View

11.

Gorbaty J, Varkey D, Hong I, Trofa D, Odum S, Piasecki D . Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta. Knee Surg Sports Traumatol Arthrosc. 2021; 30(7):2227-2234. DOI: 10.1007/s00167-021-06784-5. View

12.

Arshi A, Cohen J, Wang J, Hame S, McAllister D, Jones K . Operative Management of Patellar Instability in the United States: An Evaluation of National Practice Patterns, Surgical Trends, and Complications. Orthop J Sports Med. 2016; 4(8):2325967116662873. PMC: 5010099. DOI: 10.1177/2325967116662873. View

13.

Knapik D, Kunze K, Azua E, Vadhera A, Yanke A, Chahla J . Radiographic and Clinical Outcomes After Tibial Tubercle Osteotomy for the Treatment of Patella Alta: A Systematic Review and Meta-analysis. Am J Sports Med. 2021; 50(7):2042-2051. DOI: 10.1177/03635465211012371. View

14.

Balcarek P, Jung K, Frosch K, Sturmer K . Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Am J Sports Med. 2011; 39(8):1756-61. DOI: 10.1177/0363546511404883. View

15.

Sherman S, Erickson B, Cvetanovich G, Chalmers P, Farr 2nd J, Bach Jr B . Tibial Tuberosity Osteotomy: Indications, Techniques, and Outcomes. Am J Sports Med. 2013; 42(8):2006-17. DOI: 10.1177/0363546513507423. View

16.

Liu J, Wu H, Garcia G, Kalbian I, Strickland S, Shubin Stein B . Return to Sports After Tibial Tubercle Osteotomy for Patellofemoral Pain and Osteoarthritis. Arthroscopy. 2017; 34(4):1022-1029. DOI: 10.1016/j.arthro.2017.09.021. View

17.

Sherman S, Humpherys J, Farr J . Optimizing Patellofemoral Cartilage Restoration and Instability With Tibial Tubercle Osteotomy. Arthroscopy. 2019; 35(8):2255-2256. DOI: 10.1016/j.arthro.2019.05.013. View

18.

Xu Z, Song Y, Deng R, Ye J, Wang X, Wang H . CT and MRI measurements of tibial tubercle lateralization in patients with patellar dislocation were not equivalent but could be interchangeable. Knee Surg Sports Traumatol Arthrosc. 2022; 31(1):349-357. DOI: 10.1007/s00167-022-07119-8. View

19.

Hevesi M, Krych A . Editorial Commentary: When Properly Indicated, Combined Tibial Tubercle Osteotomy Reduces Risk of Recurrent Patellofemoral Instability More Than Does Isolated Medial Patellofemoral Ligament Reconstruction. Arthroscopy. 2023; 39(9):2046-2047. DOI: 10.1016/j.arthro.2023.04.018. View

20.

Ronga M, Oliva F, Longo U, Testa V, Capasso G, Maffulli N . Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med. 2009; 37(9):1735-42. DOI: 10.1177/0363546509333482. View