Patellofemoral Instability: Video Presentation of MPFL Reconstruction and TTO Distalization Part 2-Lateral Lengthening and MPFL Reconstruction.

Patellofemoral instability is a common problem that requires personalized treatment for each patient based on the relevant pathoanatomy. There are many ways to perform soft tissue and osteotomy procedures, and here we present our lead author's treatment algorithm, operative technique, and postoperative protocol. Medial patellofemoral ligament (MPFL) reconstruction, vastus medialis obliquus (VMO) advancement, and MPFL repair are indicated in patients with unsuccessful nonsurgical treatment after primary dislocation, those with significant osteochondral fracture, and patients with excessively high-risk factors after primary dislocation. Osteotomy is a consideration in those with elevated tibial tuberosity-trochlear groove (TT-TG) or patellar alta, while lateral retinacular lengthening is indicated for those with lateral patellar tilt. In part 2 of this 2-part series, we demonstrate the soft tissue components of this case, including lateral retinacular lengthening, MPFL reconstruction, VMO advancement, and MPFL repair. Lateral retinacular lengthening is shown to correct patellar tilt and allow for eversion of the patella. Once adequately lengthened, MPFL reconstruction is performed to enable a checkrein to resist lateral translation, particularly in 0° to 30° of flexion, before the patella engages the trochlea. Native MPFL imbrication is performed to further reinforce the reconstruction, and VMO advancement allows for dynamic medialization force. Patients can expect improved clinical and functional outcomes with tibial tubercle osteotomy (TTO) when appropriately indicated, with reliable patellar stability and low rates of complications. In patients with an elevated Caton-Deschamps Index >1.4 or TT-TG >20, TTO can lead to very high patient satisfaction, improved clinical outcomes, and low re-dislocation rates. Even in patients with a "gray" zone TT-TG of 17 to 20 mm, Level II evidence has shown improved patient-reported outcomes with the addition of TTO. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.