# Headless Screw Fixation Is Associated with Reduced Hardware Removal After Tibial Tubercle Osteotomy: A Retrospective Cohort Study

## TL;DR

Using headless screws in tibial tubercle osteotomy reduces the need for hardware removal and reoperations compared to traditional screws.

## Contribution

This study is the first to directly compare headless and headed screws in TTO for patellofemoral instability.

## Key findings

- Headless screws had zero cases of symptomatic implant removal, while headed screws had 13.2%.
- Reoperation rates were significantly lower in the headless screw group (3.6% vs. 26.3%).
- Functional outcomes were similar between the two groups.

## Abstract

Background/Objectives: Symptomatic hardware removal remains the most frequent cause of reoperation after tibial tubercle osteotomy (TTO), with removal rates reported as high as 49%. Headless compression screws have been proposed as a low-profile alternative to conventional screws to reduce hardware-related morbidity, yet no study has directly compared their use with headed screws in TTO for patellofemoral instability. This study aimed to compare complication rates and the frequency of hardware removal between headless and headed screw fixation in TTO. Methods: A retrospective review was conducted on 84 patients (94 knees) who underwent TTO between 2014 and 2024. Patients were divided into two groups based on the type of fixation used: headless screws (56 knees) and headed screws (38 knees). Demographic characteristics, perioperative variables, functional outcomes (Kujala, Lysholm, and Tegner scores), complications, and reoperation rates were compared with a minimum one-year follow-up. Results: No significant differences were found between the groups in terms of baseline demographic and clinical characteristics. Symptomatic implant removal occurred in 13.2% of the headed screw group and in none of the patients in the headless screw group (p = 0.001). Reoperation for any reason was significantly lower in the headless group (3.6% vs. 26.3%, p = 0.002). Functional outcomes were similar between groups. Post-hoc power analysis confirmed sufficient statistical power (98.8%) to detect differences in implant removal rates. Conclusion: Headless screw fixation in TTO was associated with significantly lower rates of hardware-related reoperations and painful implant removal, while achieving functional outcomes similar to those with headed screws. Headless screws may represent a preferable fixation method for reducing implant-related complications in TTO.