Pain and Hardware Removal After Tibial Tubercle Osteotomy: Incidence, Associated Factors, and Outcomes

While patients may report painful or prominent hardware after tibial tubercle osteotomy (TTO), little is known about the frequency, associated factors, and outcomes after removal of symptomatic hardware.

The purpose was to investigate the incidence of hardware removal after TTO due to pain or complications, factors associated with hardware removal, and postoperative outcomes after removal. It was hypothesized that clinical outcomes would be similar between patients who underwent TTO without hardware removal and those who underwent TTOs and subsequently hardware removal.

Case-control study; Level of evidence, 3.

A retrospective analysis was performed on patients who underwent TTO at a single institution from 2000 to 2023. Age at the time of the index surgery, sex, race, body mass index, number and size of screws, tibial tubercle-trochlear groove distance, and reason for hardware removal were collected retrospectively. Knee radiographs were reviewed for measurement of soft tissue-hardware distance. Patients were contacted via email to capture final patient-reported outcome measures (PROMs). A univariate logistic regression model was used to determine factors associated with hardware removal.

A total of 152 patients representing 171 knees were included. Of the overall cohort, 38 knees (22.2%) in 32 patients underwent TTO with subsequent hardware removal. The most common reason for hardware removal was anterior knee pain (79%). Compared with patients aged 11 to 20 years, patients aged 21 to 30 years demonstrated higher odds of undergoing hardware removal (OR, 3.67; 95% CI, 1.51-9.44; P = .009). Compared with a soft tissue-hardware distance of 0 to 4.9 mm, a distance of 10.0 to 14.9 mm demonstrated lower odds of hardware removal (OR, 0.24; 95% CI, 0.07-0.84; P = .027). Visual analog scale scores (0-10 scale) improved by a mean of 3.6 points after hardware removal (P = .003). In patients undergoing hardware removal for pain, no difference in final PROMs was found compared with patients who underwent TTO without hardware removal.

Hardware removal in patients undergoing TTO was mainly attributed to hardware-related pain/irritation. On average, pain scores improved after hardware removal. There was no difference in final PROMs between patients who had their hardware removed due to pain (eg, without any clinically relevant concomitant pathology) and patients who did not require hardware removal. Size and number of screws were not associated with a subsequent hardware removal procedure. The thickness of the soft tissue envelope overlying implanted hardware was inconsistently associated with lower odds of hardware removal.