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© 2023 THE AUTHORS. ORTHOPAEDIC SURGERY PUBLISHED BY TIANJIN HOSPITAL AND JOHN WILEY & SONS AUSTRALIA, LTD.

REVIEW ARTICLE

Results of Medial Patellofemoral Ligament

Reconstruction with and without Tibial Tubercle
Transfer in Patellar Instability: A Systematic Review
and Meta-Analysis
Tianhao Xu, MD1, Yanlin Zhu, MD1, Lei Zhang, MD1, Hui-Qi Xie, MD2, Weili Fu, MD1
1
Sports Medicine Center, Department of Orthopaedic Surgery/Orthopaedic Research Institute and 2Laboratory of Stem Cell and Tissue
Engineering, Orthopaedic Research Institute, Med-X Center for Materials, State Key Laboratory of Biotherapy, West China Hospital, Sichuan
University, Sichuan, China

The optimal surgical intervention for lateral patellar instability remains a topic of controversy despite satisfactory
clinical outcomes and low re-dislocation rates reported in numerous studies following medial patellofemoral liga-
ment reconstruction (MPFLR) with and without tibial tubercle transfer (TTT). The purpose of this systematic review
and meta-analysis is to investigate the hypothesis that combining MPFLR with TTT provides reduced complication
rates and improved clinical outcomes to isolated MPFLR in patients with lateral patellar instability. We conducted a
comprehensive systematic review and meta-analysis of comparative trials involving MPFLR with and without TTT,
sourcing data from PubMed, the Cochrane Library, Embase, and Web of Science. The primary clinical outcomes ana-
lyzed included the Kujala score, the Lysholm score, complication rates, and the Caton–Deschamps index (CDI). Ran-
dom or fixed effects were used for the meta-analysis. Postoperatively, there were no significant differences
observed in the Kujala and Lysholm scores between MPFLR and MPFLR + TTT (p = 0.053). At the final follow-up,
the CDI had decreased 0.015 (95% CI 0.044, 0.013; p = 0.289) points in the MPFLR group, with no statistical
significance. In contrast, the MPFLR + TTT group demonstrated a significant decrease of 0.207 (95% CI 0.240,
0.174; p = 0.000) points in CDI. Notably, the complication rate was higher in the MPFLR + TTT group compared
to the MPFLR-only group (RR = 2.472; 95% CI 1.638, 3.731; p = 0.000). Both MPFLR and MPFLR + TTT procedures
yield significant improvements in the Kujala and Lysholm scores. However, the MPFLR + TTT approach results in an
apparent improvement in CDI and corrects patellar maltracking, particularly in cases involving high tibial tuberosity-
trochlear groove (TT-TG) (>20 mm) or patella alta (CDI > 1.2), while MPFLR alone cannot. It is essential to consider
the higher complication rate of MPFLR + TTT, which suggests that MPFLR alone may be sufficient for patients with-
out high TT-TG or patella alta.
Key words: Caton–Deschamps index; Kujala score; Lysholm score; medial patellofemoral ligament reconstruction;
patella alta; tibial tubercle transfer

Introduction Treatment approaches range from soft tissue procedures to

R ecurrent patellar dislocation is a common condition

among adolescents and young adults, with a disease rate
of up to 29 per 100,000.1 The pathogenesis of this condition
is multifactorial, involving various contributing factors.
bony correction targeting anatomical abnormalities. Bony
procedures include medial or distal tubercle transfer,
while soft tissue procedures primarily involve medial
patellofemoral ligament reconstruction (MPFLR).

Address for correspondence Weili Fu, MD, Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University,
Guoxue Alley, Chengdu, Sichuan Province, Sichuan, China Fax: 028-85582994; Email: foxwin2008@163.com
Tianhao Xu and Yanlin Zhu are co-first authors and contributed equally.
Received 30 March 2023; accepted 29 July 2023

Orthopaedic Surgery 2023;15:2766–2776 • DOI: 10.1111/os.13870

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
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Medial patellofemoral ligament reconstruction has

Table 1 Inclusion and exclusion criteria in this study
been reported to provide satisfactory clinical outcomes and
reduced rates of re-dislocation in the treatment of lateral Inclusion criteria Exclusion criteria
patellar instability. The MPFL plays a crucial role in
Studies including patients Studies including patients treated
restraining lateral patellar displacement within the range of treated with MPFLR and with MPFLR or MPFLR combined
zero to 30 of knee flexion.2-5 Furthermore, it is consis- MPFLR combined with TTT with TTT for patellar instability
tently injured during all lateral patellar dislocations.6 for patellar instability
Studies reporting preoperative Studies including patients treated
Therefore, MPFL reconstruction has gained popularity as a
constitutions and with other surgery treatments for
means to address patellofemoral instability. However, the postoperative clinical patellar instability
etiology of patellar instability is complex, involving multi- outcomes after operative
ple factors,7,8 and in certain cases, the combination of treatment for patellar
instability
MPFLR with tibial tubercle transfer (TTT) may be neces- Human studies Studies that did not report both
sary. A comparative analysis of the outcomes of TTT com- preoperative constitutions and
bined with MPFLR versus MPFLR alone in patients with postoperative clinical outcomes
recurrent patellar instability and a tibial tuberosity- after operative treatment for
patellar
trochlear groove (TT-TG) distance of 17–20 mm revealed Instability
that the former group exhibited significantly greater Level I–IV evidence Non-human studies
improvement in Kujala, Lysholm, and International Knee Level V evidence, review articles,
Documentation Committee (IKDC) scores.9 Despite technical notes, current concept
articles, experimental,
numerous studies suggesting that MPFLR significantly laboratory studies, and case
improves clinical outcomes in patients with patellar reports
instability,10-12 there remains controversy regarding the
optimal approach to lower complication rates and superior Abbreviations: MPFLR, medial patellofemoral ligament reconstruction;
clinical outcomes. Hence, the purpose of this systematic TTT, tibial tubercle transfer.

review and meta-analysis is to investigate the hypothesis

that combining MPFLR with TTT provides reduced com-
plication rates and improved clinical outcomes compared
to isolated MPFLR in patients with lateral patellar
instability.
Methods
manipulation under anesthesia, superficial wound infection,
wound complications, stiffness in flexion, and patella
fracture).

A comprehensive systematic review of the literature was Quality Assessment

conducted following the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guide-
lines.13 We searched PubMed, Web of Science, Cochrane,
and Embase databases using the keywords “patellar
instability,” “MPFLR,” and “MPFLR combined with TTT”
from 1990 to 2022. Two independent reviewers meticulously
screened the English articles for inclusion, according to the
Oxford Centre of Evidence-Based Medicine Levels I to
IV. Inclusion criteria are shown in Table 1. The primary
clinical outcome parameters analyzed in this study included
the Kujala score, the Lysholm score, complication rates, and
the Caton–Deschamps index (CDI), which were analyzed
using random or fixed effects meta-analysis.
The Coleman methodology score (CMS) was used to assess
the quality of the included studies.14 The CMS evaluates
methodology based on 10 criteria and assigns a total score
between 0 and 100 points. A score of 100 indicates that the
study largely avoids the impact of chance, various biases, and
confounding factors. The final score was classified as excel-
lent (85 to 100 points), good (70 to 84 points), fair (50 to
69 points), or poor (<50 points). The subsections of the CMS
are based on the CONSORT statement for randomized con-
trolled trials and are modified to allow for other trial designs.
Two independent reviewers performed the scoring process in
duplicate for each study, and each reviewer conducted the
procedure twice to ensure accuracy.

Data Extraction Statistical Analysis

Data extraction was performed by two independent
reviewers, and any differences were reconciled by mutual
agreement. The following data were independently extracted
by the investigators: patient demographics, indications for
surgery, type of surgery, outcome measures, radiographic
measurements, and postoperative complications. Complica-
tions were categorized as functional failures (re-dislocation)
or non-functional failures (range of motion [ROM] deficit,
inability to run, persistent pain, corrected stiffness requiring
Continuous variables are reported as mean and standard
deviation (SD), while non-continuous data, such as com-
plications, are presented as frequencies and proportions.
Mean differences, 95% confidence intervals (CI), and p-
values were calculated using preoperative and postopera-
tive Kujala and Lysholm scores, as well as CDI. Relative
risks (RR), 95% CI, and p-values were calculated using pre-
operative and postoperative complication rates. In one arti-
cle, the MPFLR + TTT treatment group was further
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subdivided into MPFLR + TTm and MPFLR + TTm d,
with the mean and SD reported in each subgroup. The
mean and SD values for the MPFLR + TTT group were
calculated according to the Cochrane Handbook for System-
atic Reviews of Interventions.24
Because all studies included two treatment groups of
interest, namely MPFLR or MPFLR + TTT, a direct compar-
ison was performed using the observed data. A random-
effects meta-analysis was conducted for both groups, and the
data were analyzed using Stata version 15.0. The significance
threshold was set at p < 0.05. Heterogeneity was assessed
through visual inspection of the forest plot, as well as X2 and
I2 tests. Heterogeneity was considered significant if the I2
value exceeded 50%. A fixed-effects model was used for out-
come data with no evidence of significant heterogeneity,
while a random-effects model was used for outcome data
with evidence of significant heterogeneity.
Results
Literature Search and Study Selection
A flow diagram of study inclusions is shown in Figure 1.
A comprehensive literature search identified a total of
168 articles. After screening titles and abstracts, 164 articles
were excluded due to duplication, irrelevant content, or
MPFLR WITH/WITHOUT TTT IN PATELLAR INSTABILITY
failure to meet inclusion criteria. Full-text articles were then
assessed for eligibility, resulting in the inclusion of four arti-
cles in the present systematic review and meta-analysis.
Study Characteristics
A total of 346 knees were included in the present systematic
review and meta-analysis, with an overall mean age of
23.17 years. The mean follow-up time was 45.25 months.
Four studies were eligible for inclusion: Level I 1, Level II
1, Level III 1 and Level IV 1. It should be noted that there
was a considerable risk of bias in most of the included stud-
ies, as the majority were comparative analyses without ran-
domization. However, this reflects the current state of
research in this field (refer to Table 2 for more detailed
information on the included studies).
The MPFLR group included 233 knees, and the
procedure was performed using an autologous gracilis or
semitendinosus tendon graft. The MPFLR + TTT group
comprised 113 knees, with additional procedures performed
based on specific criteria. In one study,15 tibial tuberosity dis-
talization was performed on patients with a CDI higher than
1.2, while medialization of the tibial tuberosity was per-
formed on patients with an excessive TT-TG distance
(greater than 20 mm). In another study,16 complementary
tibial tuberosity medialization was performed if the
Figure 1 Preferred Reporting Items for
Systematic Reviews and Meta-Analyses
(PRISMA) flow diagram. The literature search
identified 168 articles. After screening titles
and abstracts, 164 articles were excluded due
to duplication, irrelevant content, or not
meeting inclusion criteria. Full-text articles
were then assessed for eligibility, and four
articles were included in the present
systematic review and meta-analysis.

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VOLUME 15 • NUMBER 11 • NOVEMBER, 2023
preoperative TT-TG distance was greater than 20 mm, and a
complementary tibial tuberosity distalization was performed
if the preoperative CDI was greater than 1.4. In a third
study,9 the TT-TG distance ranged from 17 to 20 mm, and
patients with a CDI greater than 1.4 were excluded. These
patients were then randomly assigned to either the MPFLR
or MPFLR + TTT groups. In the fourth study,17 the details
of TT-TG distance and CDI were not mentioned.
Kujala Score
At the final follow-up, the Kujala score showed a significant
increase of 23.199 (95% CI 19.786, 26.611; p = 0.0000)
points in the MPFLR group and 26.519 (95% CI 17.271,
35.766; p = 0.0000) points in the MPFLR + TTT group.
There was no significant difference in the Kujala score
between the MPFLR and MPFLR+TTT groups in the post-
operative period (95% CI 0.05, 7.22; p = 0.053), as demon-
strated in Figures 2–4.
Lysholm Score
At the final follow-up, the Lysholm score showed a signifi-
cant improvement of 29.471 (95% CI 15.751, 43.191;
p = 0.01000) points in the MPFLR group and 29.273 (95%
CI 6.454, 52.091; p = 0.012) points in the MPFLR + TTT
group. There was no significant difference in the Lysholm
score between the MPFLR and MPFLR + TTT groups dur-
ing the postoperative evaluation (95% CI 3.51, 4.19;
p = 0.862). (See Figures 5–7 for details.)
Clinical Displacement Index
At the final follow-up, the CDI decreased by 0.015 points
(95% CI 0.044, 0.013; p = 0.289) in the MPFLR group, but
the difference was not statistically significant. In contrast, the
CDI decreased significantly by 0.207 points (95% CI 0.240,
0.174; p = 0.000) in the MPFLR + TTT group. No signifi-
cant difference in CDI was observed between MPFLR and
MPFLR + TTT in postoperative evaluation (95% CI 0.29,
0.12; p = 0.433). These findings are presented in
Figures 8–10.
Complication Rate
In total, five patients (2.1%) in the MPFLR group and two
patients (1.8%) in the MPFLR + TTT group experienced
Table 2 Details of the articles included
Author Mean age (years) Female/male
Mulliez et al.15 22.8 81/48
Franciozi et al.9 26.8 28/14
Neri et al.16 24 82/51
Watanabe et al.17 18 30/12
Abbreviation: CDI, Caton–Deschamps index.
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MPFLR WITH/WITHOUT TTT IN PATELLAR INSTABILITY
postoperative patellar re-dislocation/instability. The inci-
dence of postoperative ROM deficit was n = 7 (3.0%) in the
MPFLR group and n = 4 (3.5%) in the MPFLR + TTT
group. Other complications in the MPFLR group included
postoperative patellar fractures in one patient (0.43%), MPFL
revisions due to tightness in two patients (0.85%), and fixa-
tion anchor revisions in two patients (0.85%). Four patients
required mobilization under general anesthesia (1.7%). In the
MPFLR + TTT group, the remaining complications were
related to fixation screw revisions in 13 patients (11.5%) and
wound infection in two patients (1.8%). The overall compli-
cation rate was higher in the MPFLR + TTT group com-
pared to the MPFLR group (RR = 2.472; 95% CI 1.638,
3.731; p = 0.000). (Figure 11).
Quality Assessment
The mean CMS score for the included studies was 80 points,
ranging from 77 to 84, indicating a generally good quality of
the studies. Furthermore, no significant difference was
observed between the mean CMS values calculated by the
two examiners, indicating the reliability of the CMS score
assessment.
Discussion
Summary and Interpretation of Key Findings
All studies included in our investigation centered on two
treatment groups, namely MPFLR and a combination of
MPFLR with TTT (MPFLR + TTT). Direct comparison
between these two groups was enabled by the availability
of observed data, a feature not found in previous reviews.
Our study revealed crucial insights, specifically that
MPFLR combined with TTT is often performed in patients
with high TT-TG (TT-TG > 20 mm) or patella alta
(CDI > 1.2).18,19
MPFLR + TTT Has Non-inferior Clinical Outcomes
Compared to MPFLR
Our study demonstrated a significant improvement in
Kujala and Lysholm scores for both the MPFLR and
MPFLR + TTT groups between preoperative and postoper-
ative assessments. However, there was no statistically sig-
nificant difference in the postoperative scores between the
Mean follow-up (m) Index included Level of evidence
12 Kujala/CDI/complication rates I
41 Kujala/Lysholm/complication rates II
76 CDI/complication rates IV
52 Lysholm/complication rates III
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Figure 2 Forest plot of the comparison of the Kujala score preoperatively and postoperatively in the medial patellofemoral ligament reconstruction
(MPFLR) group. WMD, weighted mean difference.

Figure 3 Forest plot of the comparison of the Kujala score preoperatively and postoperatively in the medial patellofemoral ligament reconstruction
(MPFLR) + tibial tubercle transfer (TTT) group. WMD, weighted mean difference.
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Figure 4 Forest plot of the comparison of postoperative Kujala score between medial patellofemoral ligament reconstruction (MPFLR) and MPFLR+
tibial tubercle transfer (TTT). WMD, weighted mean difference.

Figure 5 Forest plot of the comparison of Lysholm score between preoperative and postoperative in the medial patellofemoral ligament
reconstruction (MPFLR) group. WMD, weighted mean difference.
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Figure 6 Forest plot of the comparison of the Lysholm score preoperatively and postoperatively in the medial patellofemoral ligament reconstruction
(MPFLR) + tibial tubercle transfer (TTT) group. WMD, weighted mean difference.

Figure 7 Forest plot of the comparison of postoperative Lysholm score between MPFLR and medial patellofemoral ligament reconstruction (MPFLR)
+ tibial tubercle transfer (TTT). WMD, weighted mean difference.
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Figure 8 Forest plot of the comparison of Caton-Deschamps index (CDI) preoperatively and postoperatively in the medial patellofemoral ligament
reconstruction (MPFLR) group. WMD, weighted mean difference.

Figure 9 Forest plot of the comparison of Caton–Deschamps index (CDI) preoperatively and postoperatively in the medial patellofemoral ligament
reconstruction (MPFLR) + tibial tubercle transfer (TTT) group.
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Figure 10 Forest plot of the comparison of postoperative Caton–Deschamps index (CDI) between the medial patellofemoral ligament reconstruction
(MPFLR) and MPFLR+ tibial tubercle transfer (TTT).

Figure 11 Forest plot of the comparison of postoperative complication rate between the medial patellofemoral ligament reconstruction (MPFLR) and
MPFLR+ tibial tubercle transfer (TTT). RR, relative risks.
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two treatment groups. This indicates that MPFLR com-
bined with TTT yields favorable clinical outcomes, despite
the procedure being more invasive. Moreover, a recent
randomized controlled trial comparing tibial tubercle oste-
otomy (TTO) + MPFLR versus TTO alone found that the
combined procedure resulted in better patient satisfaction
and fewer instances of instability or functional failure, fur-
ther supporting the efficacy of MPFLR + TTT.20 These
findings can aid surgeons in providing patients with
informed consent by providing insight into the long-term
post-surgical outcomes associated with these surgical
procedures.
MPFLR + TTT Improved CDI More than MPFLR
Our findings indicate that there was no significant decrease
in CDI following MPFLR, suggesting that this surgical proce-
dure has little impact on CDI. However, significant improve-
ment in CDI was observed in the MPFLR + TTT group,
indicating that the addition of TTT to MPFLR has a substan-
tial impact on CDI. Although there was no statistically sig-
nificant difference in postoperative CDI between the MPFLR
and MPFLR + TTT groups, the improvement in CDI from
the baseline was greater in the MPFLR + TTT group. This
suggests that the improved patellofemoral tracking achieved
by the biomechanical advantages of TTT may contribute to
this improvement.
MPFLR+TTT has a Higher Complication Rate than
MPFLR
It is noteworthy that the complication rate in MPFLR
+ TTT was higher than that in MPFLR. It is important for
surgeons to carefully monitor and inform patients about
potential complications, particularly patellar re-dislocation
and stiffness, which can have multifactorial causes that need
to be analyzed thoroughly. Patellar re-dislocation may be
related to maltracking of the patella, while stiffness may be
related to soft tissue irritation due to hardware and femoral
tunnel malpositioning. Some authors have suggested that
femoral malpositioning can result in overconstraint of the
patella.21 However, no significant correlations have been
observed between femoral tunnel malpositioning and unfa-
vorable functional outcomes or between malpositioning and
stiffness level of extension. Anterior and proximal mal-
positioning have been found to be related to reduced flexion
(≤120 ), and a significant correlation has been observed
between malpositioning and a stiffness level of flexion
(p < 0.01). Most complications in MPFLR + TTT involve
fixation screws revision, and the additional TTT procedure
increases the chances of tibial fracture and reoperation due
to symptomatic hardware removal.22 Therefore, it is essential
to fully penetrate the screws into the bone and cover them
with the medial retinaculum to prevent soft tissue irritation.
Surgeons should take extra care when performing the com-
bined procedure and inform patients about the possible risks
and complications.
MPFLR WITH/WITHOUT TTT IN PATELLAR INSTABILITY
MPFLR May Not Provide Adequate Correction in
Individuals with Preoperative Pathologic Patellar Tilt
Greater than 40
In addition to CDI and TT-TG, there have been numerous
investigations into patellar tilt. Damasena et al. conducted
research demonstrating that an isolated MPFLR could
decrease patellar tilt.20 These findings were corroborated by
Neri et al., who observed a noteworthy correlation between
the correction of patellar tilt and improvement in functional
scores.16 However, qualitative analysis suggests that this cor-
rection may not be adequate for individuals with a preopera-
tive pathological patellar tilt exceeding 40 .
Limitation
This study has several limitations, mainly pertaining to the
quality of the included studies, which were comparative tri-
als and not randomized controlled trials. Nevertheless, both
the MPFLR and MPFLR+TTT groups showed acceptable
CMS values. It is noteworthy that TT-TG distance is a cru-
cial factor in knees with patellar instability.23 Moreover, a
previous study has suggested a prognostic impact of TT-TG
distance following MPFLR.15 However, the four studies that
were selected in our study had inconsistent TT-TG values,
which may introduce bias to the results. In two studies,
MPFLR with TTT was only performed on patients with
TT-TG above 20 mm.15,16 In another study, patients with
TT-TG of 17 to 20 mm were randomly assigned to MPFLR
and MPFLR + TTT groups,9 and in Watanabe et al.,17 the
TT-TG was not reported. However, due to the insufficient
number of current studies, further subgroup analysis could
not be conducted. Despite these limitations, this study pro-
vides a quantitative comparison of MPFLR and MPFLR
+ TTT procedures for patients with patellar instability and
is, therefore, a valuable contribution to the literature. In
view of our comprehensive literature review, it is important
to recognize that the inherent limitations in the available
studies have resulted in inconsistencies in TT-TG measure-
ments. These inconsistencies pose challenges in establishing
definitive conclusions with a high level of certainty. Future
well-designed randomized controlled trials with precise pre-
operative analysis and adoption of new instability-related
outcome measures are needed to identify a detectable clini-
cal difference between patients treated with and without
TTT. Moreover, to gain a deeper understanding and enable
more precise subgroup analyses, further studies are
warranted.
Conclusion
I n conclusion, it can be inferred that both the MPFLR and
MPFLR + TTT groups achieved substantial improvements
in Kujala and Lysholm scores. While MPFLR alone cannot
correct patellar maltracking, the MPFLR + TTT group
exhibited a significant enhancement in CDI and a correction
of patellar maltracking. In patients with a high TT-TG (TT-
TG > 20 mm) or patella alta (CDI > 1.2), combining MPFL
reconstruction with TTT may yield greater benefits.
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However, MPFLR + TTT carries a higher complication rate.
For patients without a high TT-TG or patella alta, MPFL
reconstruction alone may suffice.
Author contributions
T ianhao Xu, Yanlin Zhu, Lei Zhang, and Weili Fu assisted
in designing the study and helped in the interpretation
of the study. Yanlin Zhu conducted a statistical analysis and
participated in most of the study steps. Yanlin Zhu and Lei
Zhang prepared the manuscript. Tianhao Xu and Hui-Qi Xie
participated in the revision of the manuscript. All authors
read and approved the final manuscript.
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MPFLR WITH/WITHOUT TTT IN PATELLAR INSTABILITY
Conflict of Interest
T he authors declare that they have no competing
interests.
Ethics approval and consent to participate
N ot applicable.
Consent for publication
N ot applicable.
Data Availability Statement
The datasets during the current study are available from the
corresponding author upon reasonable request.
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