Editorial Commentary: Anteriorizing Tibial Tubercle Osteotomies Re-emerge Without Wound Complications of the Past, but Where Do They Fit in the Evolving State of Patellofemoral Pain Management?

Abstract

A more posteriorly located tibial tubercle relative to the trochlear groove-conceptualized as a greater sagittal tibial tubercle-trochlear groove magnitude-has been associated with patellofemoral chondral defects and is considered a potential proxy for patellofemoral contact pressures. Thus, it stands to reason that a pure anteriorizing tibial tubercle osteotomy (aTTO) could be utilized in the treatment of patellofemoral compartment pathology in patients without coronal or axial plane mal-alignment. However, pure anteriorizing osteotomies have historically been associated with an unacceptably high wound complication rate. The wound complications that have plagued this procedure appear to be avoidable with technical modifications such as utilizing laterally based incisions over a more robust tissue envelope and limiting anteriorization to 10-15mm, an amount which has previously been shown to reduce patellofemoral contract forces 30% to 60%. Several important questions remain. The authors have showed the safety of aTTO in treatment of select patellofemoral patients without coronal or axial malalignment, but how effective is it? Would the reduction of patellofemoral contact forces from an aTTO alone be enough to provide a meaningful reduction of symptoms, or would an aTTO most impactful when coupled with restorative procedures? We have not yet defined what "normal" and "abnormal" sagittal tibial tubercle-trochlear groove values are to help guide decision making. We must also develop a more thorough understanding of how tibial tubercle and trochlear morphology influence sagittal plane mechanics. The aTTO is a promising new tool with a seemingly lower complication rate than historic predecessors, though its precise role in patellofemoral pain management remains to be determined.