Editorial Commentary: When Properly Indicated, Combined Tibial Tubercle Osteotomy Reduces Risk of Recurrent Patellofemoral Instability More Than Does Isolated Medial Patellofemoral Ligament Reconstruction.

Clinical recognition and surgical treatment of patellofemoral instability has evolved dramatically over the past 3 decades. However, few patellofemoral patients present with an isolated medial patellofemoral ligament (MPFL) tear. Rather, patients often demonstrate patella alta, increased tibial tubercle to trochlear groove (TT-TG) distance, dysplasia, coronal malalignment, or combinations thereof. Given this, concomitant procedures such as tibial tubercle osteotomy (TTO) have become increasingly popularized, given their ability to anteriorize, medialize, and even distalize the patella to correct tracking. It is generally recommended that concurrent TTO be considered with primary medial patellofemoral ligament reconstruction (MPFLR) in patients with closed physes whose TT-TG distance is larger than 17 to 20 mm. MPFLR + TTO is generally safe and may decrease risk of revision surgery when compared with isolated MPFLR in properly indicated patients. However, it important to measure both knee rotation angle and tibial tubercle lateralization on magnetic resonance imaging, as both factors influence TT-TG. In patients in whom abnormal knee rotation angle is felt to be the primary driver of TT-TG, surgeons should proceed with caution when considering concomitant TTO. The pen may be mightier than the sword, but the osteotome may be mightier yet than the scalpel.