Patellofemoral Instability: Video Presentation of MPFL Reconstruction and TTO Distalization Part 1-Background and TTO.

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 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 or patellar alta, while lateral retinacular lengthening is indicated for those with lateral patellar tilt. In part 1 of this 2-part series, diagnostic arthroscopy and tibial tubercle osteotomy (TTO) are demonstrated. In this patient case, both distalization and medialization are required. Diagnostic arthroscopy is performed, and in particular, the important role of the superomedial viewing portal is shown to assess patellar tracking and trochlear dysplasia better. Exposure and osteotomy of the tibial tubercle are shown, including predrilling unicortical holes in the planned osteotomy before completion with osteotomes. The distalization is measured and performed, and the tubercle is translated both medially by 1 cm and distally by 2 cm. Patients can expect improved clinical and functional outcomes with patellar stability and low rates of complications. PFI requires a patient-specific approach that takes into account the patient's relative pathoanatomy and a surgical plan aimed at addressing each component. Multiple known risk factors can help predict the risk of recurrent instability and guide patient-informed decision-making. Consistent indications and technique can lead to very high patient satisfaction and improved clinical outcomes. 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.