From Instability to Overload: A Three-Dimensional and Condition-Specific Approach to Tibial Tubercle Osteotomy

Tibial tubercle osteotomy (TTO) is a versatile realignment procedure used to address patellofemoral instability, maltracking, overload, chondral disease, and combined deformities. Modern approaches emphasize individualized, multiplanar correction based on detailed anatomic drivers. A scoping review was conducted following PRISMA guidelines to identify studies describing patient-specific planning strategies, imaging-based thresholds, and outcomes of TTO. Fourteen studies met the inclusion criteria. Thresholds for medialization (TT-TG >12.5 to 20 mm), distalization (Caton-Deschamps ≥1.2 to 1.4), and anteriorization (5 to 10 mm) varied, with most authors aiming for postoperative normalization rather than a general or maximal correction. Five studies compared outcomes by threshold selection. Evidence supports vector-specific correction to optimize patellar entry, tracking, and load distribution, though multiplanar planning remains heterogeneously applied. Individualized TTO planning relies heavily on 2D thresholds despite the multidimensional nature of patellofemoral pathology. Emerging 3D imaging and patient-specific techniques show promise, but validated protocols for selecting combined corrective vectors are still lacking.