Comparison between infrapatellar and suprapatellar approaches for intramedullary nailing for the fractures of the tibial shaft

The efficacy of suprapatellar, parapatellar and infrapatellar intramedullary nailing in the treatment of tibial fractures: a systematic review and meta-analysis

BACKGROUND

Tibial fractures are common and challenging orthopedic injuries that are commonly treated with intramedullary nailing techniques via suprapatellar (SP), parapatellar (PP), and infrapatellar (IP) approaches. This study aimed to provide a comprehensive comparative analysis of the efficacy of different treatment approaches based on clinical outcomes.

METHODS

We conducted a detailed search in PubMed, Cochrane Library, Embase, and Web of Science for clinical studies comparing suprapatellar, parapatellar, and infrapatellar approaches in intramedullary nailing of tibial fractures. Inclusion criteria included randomized controlled trials and retrospective cohort studies involving patients aged 18 and older, comparing outcomes of these surgical techniques. Exclusion criteria included studies with insufficient data, non-English publications, and those focusing on non-tibial fractures.

RESULTS

A total of 15 studies involving 1396 patients were included in meta-analysis. Pooled results indicated that, compared to IP nailing, the SP approach significantly reduced fluoroscopy time (MD = - 35.63, 95% CI - 39.37 to - 31.89, p < 0.001), operative time (MD = - 10.72, 95% CI - 17.30 to - 4.15, p = 0.001), pain scores (SMD = - 1.49, 95% CI - 2.36 to - 0.62, p < 0.001), and improved Lysholm scores (MD = 5.74, 95% CI 3.29 to 8.19, p < 0.001) and malalignment rate (RR = 0.24, 95% CI 0.08 to 0.68, p = 0.008). Quality of life assessments also indicated higher physical component scores for the SP group (MD = 6.68, 95% CI 5.19 to 8.17, p < 0.001).

CONCLUSION

The SP approach provides significant intraoperative and postoperative benefits, reducing surgery time and improving patient outcomes in pain management and knee joint function. These findings support the SP approach as a preferred option for surgical treatment of tibial fractures.

A systematic review and meta-analysis comparing suprapatellar versus infrapatellar approach intramedullary nailing for tibal shaft fractures

BACKGROUND

The application of the suprapatellar (SP) approach has challenged the traditional infrapatellar (IP) approach in the surgery treatment of tibial shaft fractures, yet the advantages and disadvantages still remain controversial. We included more high-quality studies for this meta-analysis and systematic review to evaluate the clinical outcomes and prognosis of both approaches and thus to provide new ideas for surgeons.

METHOD

We searched literatures from PubMed, Cochrane Library, Web of Science, and EMBASE databases from January 2000 to December 2022. We extracted general information including sample size, gender, proportion of open fracture, follow-up time, and outcome indicators including entrance accuracy, fluoroscopy time, operation time, intraoperative blood loss, Lysholm score, VAS pain score, range of motion (ROM) function score, reposition accuracy, and revision cases. Cochrane Collaboration's tool and the Newcastle-Ottawa Scale were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

A total of 23 studies were generated that qualified for inclusion, 17 of which were used for meta-analysis. This study found statistically significant differences in coronal plane entrance accuracy, fluoroscopy time, Lysholm score, and VAS pain score.

CONCLUSION

The results of our meta-analysis showed that the SP approach was significantly better than the IP approach in angle and distance entrance accuracy of coronal plane, angle entrance accuracy of sagittal plane, fluoroscopy time, Lysholm score, and VAS pain score. There were no significant differences in sagittal angle accuracy, operative time, intraoperative blood loss, and ROM score.

Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis

OBJECTIVES

To compare patient-reported outcome measures (PROMs) between patients who underwent intramedullary nail (IMN) fixation for tibial shaft fractures using an infrapatellar (IP) or the newer suprapatellar (SP) approach. Secondary outcomes included fluoroscopic radiation exposure, operative time, and radiographic outcomes.

DATA SOURCES

A systematic literature search of the databases Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials Study Selection.

STUDY SELECTION

Level I to III studies in which patients over the age of 18 years with acute tibial shaft fractures who underwent tibial IMN fixation using an IP or SP approach for fracture fixation were assessed for inclusion. Studies with a minimum of 10 patients in each cohort that reported on postoperative patient-reported outcomes with at least 6 months of follow-up were included for analysis.

DATA EXTRACTION AND SYNTHESIS

Twelve studies that reported PROMs and compared IP and SP intramedullary nailing of tibial shaft fractures were analyzed. This included 654 patients who underwent IP IMN fixation and 542 patients who underwent SP IMN fixation. A random-effects model for unadjusted/crude study estimates were pooled using inverse variance (IV) weighting for continuous variable analysis.

CONCLUSIONS

This review found a significant improvement in PROM for patients with tibial shaft fractures when the SP IMN technique was used. In addition, there was a significant decrease in intraoperative fluoroscopy time consistent with other radiographic findings demonstrating improved start point accuracy and reduction with SP IMN fixation of tibial shaft fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Removing a suprapatellar intramedullary nail via a suprapatellar approach: a retrospective cohort study

BACKGROUND

Over the last 20 years, suprapatellar (SP) intramedullary nailing has gained considerable attention for treating tibia fractures and is believed to improve fracture alignments, decrease anterior knee pain, and facilitate intraoperative fluoroscopy. However, it is associated with various concerns, including the need to make another infrapatellar (IP) incision to remove the nail.

AIMS

This study was aimed at developing a new technique for the removal of SP tibial nails through an SP approach using a cannulated extraction system. The efficiency of the novel SP approach was compared to that of the traditional IP approach for the removal of SP tibial nails.

PATIENTS AND METHODS

This was a retrospective cohort study from a prospectively collected clinical registry. The data for 69 consecutive patients who received surgery to remove a previous SP intramedullary nail using an SP approach (n = 30, SP cohort) or an IP approach (n = 39, IP cohort) were analyzed. Intra-operative evaluations included intraoperative blood loss, operation time, and changes in the surgical procedures. At six months follow-up, post-operative Lysholm knee score, visual analog scale (VAS) score, and the active range of motion (ROM) of the affected knee and complications were assessed.

RESULTS

Patients in the SP cohort exhibited an increased post-operative Lysholm knee score (β, 2.6; 95% confidence interval [CI], 0.6 to 4.6; P = 0.012), decreased post-operative VAS score (β, - 0.7; 95% CI, - 1.1 to - 0.2; P = 0.004), and increased operation time (β, 9.8 minutes; 95% CI, 5.7 to 14.0 minutes; P < 0.001) compared with those treated with the IP approach after adjustment for baseline characteristics. There were no statistically significant differences in blood loss, post-operative ROM, or complications between the two cohorts.

CONCLUSIONS

Compared with the IP technique, the SP approach for the removal of an SP tibial nail was independently associated with an increased post-operative Lysholm knee score and decreased VAS score, although the surgery was longer in duration. The novel technique offers a reliable and minimally invasive option for the removal of an SP tibial nail.