Off With the Head: Decreasing Complications With Headless Compression Screws for Tibial Tubercle Fracture Fixation

INTRODUCTION: Tibial tubercle fractures' (TTF) preferred repair technique with headed cannulated screws is associated with reoperation rates of 50% to 60% for removal of hardware (ROH). A newer screw design is headless compression screws (HCS).

AIM: This project hypothesized that utilization of lower-profile HCS would reduce rates of pain and reoperation rates for removal of hardware in pediatric TTF, while maintaining comparable fracture healing and functional outcomes.

METHODS: An institutional review board approved, multicenter, retrospective, case-control study with data collected for all surgeries between 2014 and 2024. A priori power analysis was performed, targeting significant reduction in ROH rates.

RESULTS: A total of 283 TTF were identified; 148 met inclusion criteria, with most excluded for alternative fractures, surgical treatment, or insufficient follow-up. 121 were treated with cannulated, headed screws and 27 with HCS. Patients were 93.2% male, most commonly black (55%), average age 14.5 years, weight 85th percentile, height 71st percentile, and body mass index of 79th percentile. Injuries were most often during basketball (47%). All fracture patterns from Ogden 1A to 4B were represented, and the most common pattern was 3A (31%); no patterns were excluded. The typical repair consisted of 2 to 3 screws of 4.5 to 5.5 mm diameter, and 28% with supplemental fixation. The only difference between the headed and HCS groups was washer usage (50% vs. 0%, P<0.001). Given the demographic difference in washer use, subgroup analysis was performed to separate the washer and washer-less headed cannulated screw constructs. There were no differences in postoperative management, including immobilization (71% knee immobilizer), days to motion (29), and days to weight bearing (35). Total follow-up period was similar (266 d). There were no differences in hardware failure. Neither group experienced nonunion. Compared with headed screws with washers, the HCS group had significantly less pain (38% vs. 11%, P=0.005), relatively fewer wound complications and infections (both 2.5% vs. 0%, P=0.12), and significantly lower rates of ROH (40% vs. 7.4%, P<0.001).

CONCLUSION: Compared with the preferred standard TTF fixation of headed cannulated screws, patients who received HCS had equivalent surgical, healing, and management outcomes, with relatively lower rates of wound complications and infections, significantly less pain, and significantly fewer returns to the operating room for ROH.

EVIDENCE: Level III-multicenter case-control.