Is Fixation Strategy Associated With Complication Risk in Ogden Type IV Tibial Tubercle Avulsion Fractures? A Multicenter Study of the Tibial Tubercle Study Database

The optimal surgical treatment of Ogden Type IV tibial tubercle avulsion fractures (TTAFs) remains controversial, given this injury pattern’s rarity and its multiplanar involvement of the proximal tibial physis. Small, single-center studies suggest type IV fractures have higher complication rates and more variable fixation constructs than other TTAF types. The purpose of this study is to delineate fixation constructs among surgically managed type IV TTAFs and identify factors associated with postoperative complications. A retrospective, multicenter cohort study was conducted across seven institutions examining surgically-managed Ogden IV TTAFs treated between 2007 and 2022. Patients treated nonoperatively were excluded. Patient demographics, injury characteristics, treatment strategy (including fixation construct), and post-operative complications were analyzed. Fisher exact tests were used to compare complication frequency between fixation techniques. Eighty-nine patients undergoing operative management of a type IV TTAF meeting study criteria were identified. The majority (72, 80.9%) were stabilized with screw-only constructs, while nine (10.1%) were treated with pins or hybrid pin/screw constructs and the remainder (9.0%) were treated with a plate. Among screw-only constructs, 4.5mm screws (49, 58%) with vertically-stacked orientation (37, 51.3%) were most common. Twenty-five patients (28.0%) experienced complications, the most common of which were implant irritation (14.6%) and wound problems (3.4%). One patient (1.1%) had postoperative compartment syndrome. When examining major complications (excluding implant irritation), the frequency was lower for screw-only constructs than other types of fixation (6.9% vs. 35.3%; p=0.005). For fractures fixed with screws only, there was no difference in overall complications based on the number of screws used (p=0.21). No implant failures or nonunions were observed. In this large, multicenter cohort of surgically-managed type IV TTAFs, considerable variation was observed among successful fixation constructs. Implant irritation was the most commonly observed complication. Other than implant irritation, the overall frequency of complications was low and lowest among screw-only constructs. Level III 1. A variety of fixation options exist for type IV tibial tubercle avulsion fractures 2. There was reliable healing and good outcomes in the majority of cases 3. Implant irritation is the most common complication in screw-only constructs 4. Anterior-to-posterior screws can provide acceptable fixation for type IV fractures