Systematic Review
The Incidence of Complications of Tibial Tubercle Osteotomy: A Systematic Review

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Purpose

The goal of this review was to quantify the risk of perioperative and early postoperative complications of tibial tubercle osteotomy (TTO) with different techniques.

Methods

A systematic review of multiple databases was performed to identify studies that reported complications of TTO. Complications were defined as any adverse outcome, including osteotomy site nonunion, fracture, infection, wound complications, neurovascular complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Major complications were defined as nonunion, fracture, infections/wound complications requiring return to the operating room, and DVT or PE. The risk of subsequent hardware removal was also quantified.

Results

The 19 identified studies included a total of 787 TTOs: 472 direct medialization procedures (Elmslie-Trillat technique), 193 anteromedialization procedures (Fulkerson technique), and 102 procedures in which the tibial tubercle was completely detached for medialization or distalization, or a combination. The overall complication risk was 4.6%. The risk of complications was higher when the tibial tubercle was completely detached (10.7%) than with Elmslie-Trillat (3.3%) or Fulkerson (3.7%) procedures (P = .004). The overall risk of major complications was 3.0%. Hardware removal was performed in 36.7% of osteotomies and was less frequent with the Elmslie-Trillat technique (26.8%) than with the Fulkerson technique (49.0%) or complete tubercle detachment (48.3%) (P < .001).

Conclusions

Tibial tubercle osteotomy is a complex surgical procedure with a significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained.

Level of Evidence

Level IV, systematic review of Level IV studies.

Section snippets

Methods

In October 2014, a literature search of Scopus and PubMed was undertaken. The search terms that were used included “Elmslie” or “Elmslie-trillat” or “Fulkerson” or “Tibial Tubercle Osteotomy” or “TTO” or “Distalization” or “Anteromedialization” or “Medialization” and “Dislocation” or “Subluxation” or “Instability,” with the search limited to human studies in English. The search yielded 576 proposed articles, 104 of which were duplicates. The review process of the remaining 472 articles involved

Results

The 19 studies included a total of 787 TTOs. There were 472 direct medialization procedures (Elmslie-Trillat technique) in 11 studies,10, 11, 12, 14, 15, 17, 19, 22, 23, 24, 26 193 anteromedialization procedures (Fulkerson technique) in 5 studies,9, 13, 20, 25, 27 and 102 procedures in 3 studies16, 18, 21 in which the tibial tubercle was completely detached for medialization, distalization, or a combination.

The mean patient age varied across the studies from 20 to 31 years. Seventeen of the

Discussion

The major finding of this review is that the risk of complications is higher when the osteotomy involves completely detaching the tibial tubercle (10.7%) than when attempts are made to preserve a distal cortical hinge, as with the Elmslie-Trillat (3.3%) and Fulkerson (3.7%) osteotomies.

Among the most devastating complications associated with TTO is nonunion of the osteotomy site. Six patients (0.8%) in this series had nonunion of the osteotomy site, 5 of whom required revision surgery. The risk

Conclusions

Tibial tubercle osteotomy is a complex surgical procedure with significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained.

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    See commentary on page 1826

    The authors report the following potential conflict of interest or source of funding: D.F. receives support from Vericel, DePuy Mitek, and Smith & Nephew.

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