Modifiable Risk Factors for Complications Following Surgical Treatment of Tibial Tubercle Fracture

Background: Tibial tubercle fractures (TTF) commonly occur in an athletic adolescent population and typically require operative reduction and fixation. Surgical techniques and postoperative restrictions are varied, with limited knowledge on factors that may affect outcome. We hypothesize that surgical technique and postoperative rehabilitation protocol can affect risk of postoperative complications following surgical treatment of TTF. Methods: Retrospective review was conducted including all consecutive surgically treated TTF at a single level 1 pediatric trauma center between January 2010 and December 2022. Patients were excluded for skeletal dysplasia, <10 weeks of follow-up, or periosteal avulsion only. They were classified into “accelerated” (postoperative weight-bearing and motion allowed within 21 d) or “conservative” (did not meet accelerated criteria) groups. Postoperative complications were recorded and graded by the modified Clavien-Dindo (C-D) classification. Univariate and multivariate logistic regression analysis were used to investigate factors associated with C-D grade II and III complications. Results: Totally, 183 knees (177 patients) met criteria for analysis. Median follow-up was 27.3 weeks. Fifty-three knees (29%) qualified for the “accelerated” group and 129 knees (71%) were “conservative.” Initial postoperative casting was performed in 38% of the conservative group compared with 1.9% in the accelerated group ( P <0.001). Overall complication rate was 44.3% (81/183), with 33.3% (61/183) being a grade II or III complication. The most common complication was symptomatic implant (19.7%). There were 4 cases of fracture displacement and 1 case of implant displacement, all occurring in the conservative group. In multivariate analysis female sex (OR: 4.9), initial postoperative casting (OR: 2.6), and lower BMI percentile (OR: 1.02) were independently associated with higher grade II and III complication rate, while distal repair of the avulsed periosteum was associated with lower rate (OR: 0.26). Conclusion: Postoperative casting and repair of the distal periosteal avulsion are modifiable treatment decisions impacting risk of complications following surgical treatment of TTF. Decreasing variability in care, including implementing an accelerated rehabilitation protocol, may improve outcomes. Level of Evidence: Level III.