Return-to-Play Guidelines After Patellar Instability Surgery Requiring Bony Realignment: A Systematic Review.

BACKGROUND: Recurrent patellar instability can be treated nonoperatively or surgically, and surgical management may vary based on the causative pathology in the structures surrounding the patella. Although isolated soft tissue reconstruction is among the most common operative treatments, certain patient populations require bony realignment for adequate stabilization. PURPOSE: To evaluate postoperative guidelines, including return to play and rehabilitation, after bony procedures involving the tibial tubercle for patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review on return-to-play guidelines was conducted with studies published from 1997 to 2019 that detailed procedures involving bony realignment by tibial tubercle osteotomies and tibial tubercle transfers with or without soft tissue reconstruction. Exclusion criteria included animal or cadaveric studies, basic science articles, nonsurgical rehabilitation protocols, and patients with mean age <18 years. Studies were assessed for return-to-play criteria, rehabilitation protocols, and bias. RESULTS: Included in the review were 39 studies with a total of 1477 patients and 1598 knees. Mean patient age ranged from 17.5 to 34.0 years, and mean follow-up ranged from 23 to 161 months. All 39 studies described postoperative rehabilitation; however, only 16 studies specifically outlined return-to-play criteria. The most commonly cited return-to-play criterion was quadriceps strength (62.5%). Range of motion (50.0%), physical therapy protocols (18.8%), and radiographic evidence of healing (18.8%) were other cited objective criteria for return-to-play. Four of 16 (25.0%) studies described subjective criteria for return to play, including pain, swelling, and patient comfort and confidence. Of the 11 studies that described a timeline for return to play, the range was between 2 and 6 months. CONCLUSION: The results revealed that 100% of papers evaluated lacked adequate return-to-play guidelines. Moreover, timelines significantly varied among studies. More clearly defined return-to-play guidelines after tibial tubercle transfer for patellar instability are required.