Intraarticular anatomic risks of tibial nailing

Comparison of the efficacy of intramedullary nailing via the lateral parapatellar approach versus the infrapatellar approach in the treatment of tibial metaphyseal-diaphyseal junction fractures

BACKGROUND

To compare the efficacy of intramedullary nailing via the lateral parapatellar approach versus the infrapatellar approach in treating fractures at the tibial metaphyseal-diaphyseal junction.

METHODS

A retrospective analysis was conducted on the clinical data of 45 patients with proximal or distal tibial fractures treated with intramedullary nailing via lateral parapatellar approach (n = 23) or infrapatellar approach (n = 22) between January 2019 and March 2023. We recorded and compared the operative time, intraoperative blood loss/fluoroscopies, success rate of closed reduction, anteroposterior and lateral entry point accuracy, postoperative infection, fracture healing time, as well as NRS pain scores, Lysholm knee function scores, and knee range of motion.

RESULTS

Both groups completed the surgery without any complications. The lateral parapatellar approach group had significantly better results regarding shorter operative time, less intraoperative blood loss, and fewer intraoperative fluoroscopies compared to the infrapatellar approach group (P < 0.05). All cases in the lateral parapatellar approach group achieved closed reduction, while 10 cases in the infrapatellar approach group required open reduction. Fractures in both groups healed successfully, without statistically difference in healing time (P > 0.05). The accuracy of anteroposterior and lateral entry points was better with lateral parapatellar approach (P < 0.05). At 3 and 12 months postoperatively, lateral parapatellar approach showed better Lysholm and NRS scores compared to infrapatellar approach (P < 0.05). Two groups had no significant difference in range of motion (P > 0.05).

CONCLUSIONS

Lateral parapatellar approach combined with the blocking screw technique provides superior clinical outcomes compared to infrapatellar approach in the treatment of proximal or distal tibial fractures, making it suitable for further investigation.

Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study

INTRODUCTION

The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails.

MATERIALS AND METHODS

This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated.

RESULTS

Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each.

DISCUSSION

DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results.

CONCLUSIONS

DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach

INTRODUCTION

According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches.

METHODS

Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings.

RESULTS

The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups.

CONCLUSION

The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function

BACKGROUND

The primary aim of this study was to compare the radiographic parameters (nail insertion-point accuracy [NIPA] and fracture malalignment) of patients who had undergone tibial intramedullary nailing via the suprapatellar (SP) and infrapatellar (IP) approaches. The secondary aims were to compare clinical outcomes and patient-reported outcomes (PROs) between these approaches.

METHODS

All adult patients with an acute tibial diaphyseal fracture who underwent intramedullary nailing at a single level-I trauma center over a 4-year period (2017 to 2020) were retrospectively identified. The nailing approach (SP or IP) was at the treating surgeon's discretion. Intraoperative and immediate postoperative radiographs were reviewed to assess NIPA (mean distance from the optimal insertion point) and malalignment (≥5°). Medical records and radiographs were reviewed to evaluate the rates of malunion, nonunion, and other postoperative complications. The Oxford and Lysholm Knee Scores (OKS and LKS) and patient satisfaction (0 = completely dissatisfied, 100 = completely satisfied) were obtained via a postal survey at a minimum of 1 year postoperatively.

RESULTS

The cohort consisted of 219 consecutive patients (mean age, 48 years [range, 16 to 90 years], 51% [112] male). There were 61 patients (27.9%) in the SP group and 158 (72.1%) in the IP group. The groups did not differ in baseline demographic or injury-related variables. SP nailing was associated with superior coronal NIPA (p < 0.001; 95% confidence interval [CI] for IP versus SP, 1.17 to 3.60 mm) and sagittal NIPA (p < 0.001; 95% CI, 0.23 to 0.97 mm) and with a reduced rate of malalignment (3% [2 of 61] versus 11% [18 of 158] for IP; p = 0.030). PROs were available for 118 of 211 patients (56%; 32 of 58 in the SP group and 86 of 153 in the IP group) at a mean of 3 years (range, 1.2 to 6.5 years). There was no difference between the SP and IP groups in mean OKS (36.5 versus 39.6; p = 0.246), LKS (71.2 versus 73.5; p = 0.696), or satisfaction scores (81.4 versus 79.9; p = 0.725).

CONCLUSIONS

Compared with IP nailing, SP nailing of tibial shaft fractures was associated with superior NIPA and a reduced rate of intraoperative malalignment but not of malunion at healing. However, the superior NIPA may not be clinically important. Furthermore, there were no differences in PROs at mid-term follow-up.

LEVEL OF EVIDENCE

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

Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures

PURPOSE

To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation.

MATERIALS AND METHODS

A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated.

RESULTS

Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups.

CONCLUSION

Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable.

LEVEL OF EVIDENCE

Level III.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures

PURPOSE

To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures.

MATERIALS AND METHODS

We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated.

RESULTS

The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups.

CONCLUSION

Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative.

LEVEL OF EVIDENCE

Level III.

Suprapatellar Tibial Nailing: Future or Fad?

Over the last hundred years, there have been significant advancements in the way the Orthopaedic community treats tibial fractures. More recently, the focus of Orthopaedic trauma surgeons has been comparing the different techniques of insertion for tibial nails, specifically suprapatellar (SPTN) versus infrapatellar. The existing literature is convincing that there does not appear to be any clinically significant differences between suprapatellar and infrapatellar tibial nailing, with some apparent benefits of SPTN. Based on the current body of literature and our personal experience with SPTN, we believe the suprapatellar tibial nail will become the future for most tibial nailing procedures, regardless of fracture pattern. We have seen evidence of improved alignment in both proximal and distal fracture patterns, decreased radiation exposure and operative time, relaxation of the deforming forces, ease of imaging, and static positioning of the leg, which would be helpful for the unassisted surgeon, as well as no difference in anterior knee pain or articular damage within the knee between the two techniques.

[Osteosynthesis of extra-articular proximal tibial fractures]

The treatment of extra-articular proximal tibial fractures is a therapeutic challenge due to the frequently significant soft tissue injury, the effect of the deforming forces and the need for an exact restoration of the bony alignment. Various methods of osteosynthesis are available for surgical stabilization. The locking plate osteosynthesis is the most frequently used procedure because of its good biomechanical stability, especially in osteoporotic bones, and the protection of the periosteal blood flow. Depending on the extent and stability of the defect zone, especially in the case of a medial comminuted zone and the bone quality, bilateral plate osteosynthesis can be necessary. If the proximal fragment is big enough, closed reduction and intramedullary nailing are possible. In the case of severely compromised soft tissue or very short epiphyseal fragments, the construction of an external fixator, e.g. hybrid external fixator, is recommended, which also allows definitive treatment under early full weight bearing. The most important complications are axial and torsional malalignments.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures

PURPOSE

To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures.

METHODS

Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit.

RESULTS

Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004).

CONCLUSION

Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

Defining the Ideal "Nail Exit Path" of a Tibial Intramedullary Nail-A Computed Tomography Analysis of 860 Tibiae

OBJECTIVES

To identify the ideal distal nail position in the distal tibia, using a computed tomography analysis.

METHODS

Three-dimensional models of 860 left tibiae were analyzed using the Stryker Orthopaedic Modeling and Analytics software (SOMA, Stryker, Kiel, Germany). The nail axis was defined by 7 center points at the middle of the inner cortical boundary. The point where this line fell relative to the center of the tibial plafond in both the anteroposterior and mediolateral planes was calculated.

RESULTS

The mean mediolateral offset of the tibial nail exit path was 4.4 ± 0.2 mm (95% confidence interval) lateral to the center of the tibial plafond. The mean anteroposterior offset of the tibial nail exit path was 0.6 ± 0.1 mm anterior to the center of the tibial plafond.

CONCLUSIONS

We have presented an anatomic study analyzing the ideal nail exit path using computed tomography scans of 860 tibiae. We defined that the ideal nail exit path of a tibial nail is lateral with respect to the center of the tibial plafond. This is supported by previous clinical studies and has significant implications for preventing malalignment when treating distal tibial fractures with intramedullary nailing.

Tibial alignment following intramedullary nailing via three approaches

PURPOSE

The purpose of this study is to evaluate the incidence of malalignment in patients undergoing IMN for tibial shaft fractures treated with the extra-articular lateral parapatellar, suprapatellar, and infrapatellar approaches.

METHODS

A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical centre. Quality of reduction was assessed using the following three parameters: (1) < 10°of angulation in orthogonal radiographic views (2) < 5 mm of displacement between the major fracture fragments (3) < 5 mm of gap between the major fracture fragments. A good reduction was one that met all 3 criteria, an acceptable reduction met 2 criteria, and a bad reduction met one or none of the criteria. All patients treated consecutively for tibial shaft fractures between June 1, 2019 and June 1, 2020 were identified. The final cohort included 57 tibia fractures in 56 patients. Of the 57 tibia fractures, 8 (14%) were proximal third, 32 (56%) were middle third, and 17 (30%) were distal third fractures.

RESULTS

We found no significant difference in angulation, displacement, or gapping with respect to surgical approach utilized or location of fracture (proximal or distal tibia fractures) on one-way ANOVA. Quality of reduction was rated as "good" in 48 (84%) of the cases (19 supra, 13 infra, and 16 lateral). Nine reductions (16%) met only two of the three reduction quality criteria and were considered acceptable reductions. These included 2 suprapatellar (1 > 5 mm displacement, 1 > 5 mm gapping), 4 infrapatellar (4 > 5 mm displacement), and 3 lateral extra-articular parapatellar (2 > 5 mm displacement and 1 > 5 mm gapping). No reductions were determined to be bad according the Baumgaertner et al. criteria. There was no significant difference in the rate of combined fibula fractures or the rate of fibular fixation between the three cohorts.

CONCLUSIONS

In conclusion, no significant difference was found in fracture reduction angulation, displacement, and gapping in patients treated with an IMN with respect to approach for diaphyseal or metadiaphyseal tibial shaft fractures.

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

OBJECTIVES

To assess the effectiveness of suprapatellar (SP)-nailing versus infrapatellar (IP)-nailing of tibia fractures in anterior knee pain, complications (retropatellar chondropathy, infection, and malalignment) and physical functioning and quality of life. A clinical question-driven and thorough systematic review of current literature is provided.

DATA SOURCE

PubMed and Embase databases were searched for studies published between 2010 and 2020 relating to SP and IP-nailing of tibia fractures. The study is performed in concordance with PRISMA-guidelines.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials, prospective and retrospective observational studies reporting on outcomes of interest.

DATA EXTRACTION

Data extraction was performed independently by 2 assessors. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal.

DATA SYNTHESIS

Continuous variables are presented as means with SD and dichotomous variables as frequency and percentages. The weighted mean, standardized weighted mean differences, and 95% confidence interval were calculated. A pooled analysis could not be performed because of differences in outcome measures, time-points, and heterogeneity.

RESULTS

Fourteen studies with 1447 patients were analyzed. The weighted incidence of anterior knee pain was 29% after SP-nailing and 39% after IP-nailing, without reported significance. There was a significant lower rate of malalignment after the SP-approach (4% vs. 26%) with small absolute differences in all planes. No substantial differences were observed in retropatellar chondropathy, infection, physical functioning, and quality of life.

CONCLUSIONS

This systematic review does not reveal superiority of either technique in any of the respective outcomes of interest. Definitive choice should depend on the surgeon's experience and available resources.

LEVEL OF EVIDENCE

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

Extreme Nailing or Less Invasive Plating of Lower Extremity Periarticular Fractures

Periarticular fractures of the lower extremity can be difficult injuries to stabilize effectively. Modern advances in technique and implant design now allow many of these fractures to be fixed with an extreme intramedullary nail. When nailing is not possible, less invasive plating through percutaneous incisions is a reliable option. The decision to perform extreme nailing is multifactorial and is based on the fracture pattern, the condition of the soft tissues, the medical condition of the patient, and the importance of earlier or immediate weightbearing.

Intramedullary tibial nailing using infrapatellar and suprapatellar approaches: A systematic review and meta-analysis

INTRODUCTION

Intramedullary nailing of diaphyseal tibial fractures has become the gold standard method of fixation with high rates of union and low complication rates reported. The suprapatellar (SP) approach may have many advantages over the traditional infrapatellar (IP) approach. Controversy exists due to potential damage to the patellofemoral joint leading to persistent anterior knee pain. This systematic review and meta-analysis aims to evaluate the clinical and procedural outcomes of the SP approach in comparison to the traditional IP approach.

METHOD

In this PRISMA compliant systematic review and meta-analysis, five databases including MEDLINE, EMBASE, Web of Science, Cochrane Library and CINAHL were searched from inception until May 2020. Randomised controlled trials (RCTs) and comparative observational studies involving adults with tibial fractures treated with intramedullary nail fixation using either the suprapatellar or infrapatellar approach were included. Data extracted included demographics, functional knee scores, fluoroscopy exposure, insertional accuracy and adverse events. The primary outcome was validated functional knee scores. Risk of bias was calculated using the Cochrane risk of bias tool version 2 (RoB 2) and Newcastle-Ottawa Scale (NOS).

RESULTS

In total 16 studies were included consisting of 5 RCTs and 11 comparative observational studies. This included 1750 total operations with 810 in the SP group and 940 in the IP group. Meta-analysis was performed on the studies where appropriate data was reported. The SP approach demonstrated superior Lysholm scores (Mean Difference (MD) 5.63 [95% Confidence Interval (CI): 2.81 to 8.44]), reduced fluoroscopy times (MD -38.12 sec [95% CI: -47.96 to -28.28]) and increased entry point accuracy (Standard Mean Difference (SMD) -0.90 [95% CI: -1.22 to -0.59]). No differences in complication rates or blood loss were found.

CONCLUSION

Based on the data presented in this review, intramedullary nailing of the tibia using the SP approach demonstrates superior Lysholm knee scores, greater entry point accuracy and reduced fluoroscopy exposure with equivalent risk of developing complications when compared to the IP approach.

Suprapatellar versus infrapatellar nailing for tibial shaft fractures: A comparison of surgical and clinical outcomes between two approaches

BACKGROUND

Tibial shaft fractures are a relatively common injury and contemporary treatment includes on-axis fixation with a locked intramedullary nail in the majority of cases. The conventional technique is via an infrapatellar approach but currently there is a trend towards the use of a suprapatellar approach. We compared key variables including operative time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nailing in our unit versus our previous experience of infrapatellar tibial nailing.

METHOD

Twenty-eight consecutive patients with tibial fracture underwent tibial nailing via the suprapatellar (SPN) approach. Six patients in the study group were excluded due polytrauma and need for dual orthopaedic and plastic surgery management. We compared outcomes with our most recent 20 consecutive patients who had undergone tibial nailing via an infrapatellar (IPN) approach. Primary surgical outcomes were: operative time, radiation exposure and accuracy of entry point of the nail on both anteroposterior and lateral radiographs. Clinical outcomes included time to weightbearing, time to radiographic union and patient-reported outcome score (Lysholm score).

RESULTS

Forty-eight consecutive patients underwent intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study (22 SPN vs 20 IPN). There were no significant differences in patient demographics or injury patterns between the two groups. Operative time and radiation exposure were significantly lower in the SPN group when compared to the IPN group (115 min vs 139 min ± 12.5) (36 cGY/cm² vs 76.33 cGY/cm² +/- 20.1). Furthermore, patients in the SPN group reported superior outcome scores at a mean follow up of 3 months (8-24 weeks) There were no observed differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months.

CONCLUSION

Our study shows that adoption of the SPN approach requires minimal learning curve, and has the potential benefits of reduced operative time, radiation exposure and superior patient reported outcomes when compared to the conventional infrapatellar approach.

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

INTRODUCTION

This study aimed to compare the outcomes at the clinical and functional levels of suprapatellar (SP) and infrapatellar (IP) approaches for intramedullary nailing in treating tibial shaft fracture.

METHODS

Patients who underwent tibial shaft fracture intramedullary nailing by the SP approach or IP approach in a trauma center were retrospectively reviewed. The demographics, intraoperative fluoroscopy time, operation time, blood loss, irrigation volume, postoperative X-ray alignment, and complications of patients were compared between the two groups under different approaches. Lysholm knee score, visual analog score (VAS), and incidence of anterior knee pain (AKP) were assessed 1 year after surgery.

RESULTS

The study finally included well-documented 81 patients (38 SP versus 43 IP). The SP group exhibited significantly shorter intraoperative fluoroscopy time than that of the IP group (81.7 ± 14.5 s vs. 122.0 ± 24.3 s, P < 0.001). Both aspects recorded a precise reduction of the fracture: angulation (2.1 ± 1.2° vs 3.1 ± 1.5°, P < 0.05) and translation (0.6 ± 0.8 mm vs 1.4 ± 1.5 mm, P < 0.05) in the coronal plane in the SP group. However, the sagittal plane recorded no such change (P > 0.05). The Lysholm knee score was higher in the SP group than that of the IP group (87 ± 8 vs. 80 ± 15, P < 0.05). The SP group displayed an evidently lower average VAS score than that of the IP approach group (0.3 ± 0.8 vs 1.3 ± 1.4, P < 0.001). Six cases (16%) in the SP group and 16 cases (37%) in the IP group experienced AKP 1-year post-operation (P < 0.05). As far as complications are concerned, neither group showed any significant difference (P > 0.05).

CONCLUSION

Compared with the IP approach, the application of intramedullary nailing through the SP approach in treating tibial shaft fractures can effectively shorten the intraoperative fluoroscopy time, correct coronal plane angulation and translation deformity, reduce the incidence of AKP and improve postoperative function.

The Influence of Sagittal Proximal Tibial Anatomy in Tibial Intramedullary Nailing

OBJECTIVES

To quantify anatomic variation in sagittal proximal tibial anatomy and determine if anatomy or nail insertion method influences the radiographic nail position.

DESIGN

Retrospective cohort of prospectively collected data.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Forty-five patients with 46 tibia fractures (OTA/AO 41A, 42, and 43) treated with infrapatellar (IP) or suprapatellar (SP) nailing. The average patient age was 40.6 years (range 19-62 years).

INTERVENTION

Patients received IP or SP nailing. Cohorts were analyzed based on the nailing technique and proximal tibial anatomy.

MAIN OUTCOME MEASUREMENTS

Proximal tibial radiographic anatomy was quantified using novel measurements [anterior tubercle angle (ATA) and entry point position (EPP)]. Nail entry point, entry point displacement after reaming, nail position, and quality of reduction was measured and compared between groups.

RESULTS

ATA was highly variable between patients. ATA was strongly correlated with EPP with a higher ATA associated with EPP more colinear with the intramedullary canal. Patients with low ATA treated with IP nailing had significantly longer operative times (60.0 vs. 45.7 minutes). Low ATA tibias had a higher incidence of entry point displacement due to eccentric reaming compared with high ATA tibias (70% vs. 38%) with the highest incidence of entry point displacement and absolute displacement in low ATA tibias treated with IP nailing (86%, 2.8 mm). SP nailing demonstrated shorter operative times relative to IP nailing (45.5 vs. 55.6 minutes).

CONCLUSIONS

There is considerable variability in proximal tibial anatomy and these features influences the nail position within the tibia. These differences in anatomy should be considered to potentially reduce operative times, entry point displacement and anteriorization of tibial nails.

LEVEL OF EVIDENCE

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

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point

INTRODUCTION

Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation.

METHODS

Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured.

RESULTS

Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated.

DISCUSSION

Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point.

LEVEL OF EVIDENCE

Therapeutic level III.

A comparison of the use of a suprapatellar Chinese Aircraft-shaped Sleeve System versus suprapatellar intramedullary nailing for tibial shaft fractures: Outcomes over a one-year follow-up

INTRODUCTION

This study aimed to investigate the effectiveness and safety of the Chinese Aircraft-shaped Sleeve (CASS) system on the clinical outcomes of tibial intermedullary nailing using a suprapatellar approach for the treatment of tibial fractures in a cohort of adult Chinese patients over a minimum one-year follow-up.

METHODS

After institutional review board approval, skeletally mature patients with Orthopaedic Trauma Association (OTA) type 42 tibial shaft fractures were randomized into either a SP approach using CASS group or a conventional SP approach group after informed consent was obtained. The operations were performed by a single senior orthopaedic surgeon according to group assignments. A group of 33 patients were treated using the CASS system and the other group of 34 patients were treated using a conventional SP approach. Both groups fully complied with research requirements and completed 12 months of follow-up. Magnetic resonance images (MRI) were obtained for the evaluation of the patellofemoral joint (PFJ) and residual debris preoperatively, as well as one week and 12 months postoperatively. Radiographs were used to assess alignment and union, visual analog scores (VAS) were used to assess anterior knee pain, and range of motion (ROM) and the Lysholm knee scoring scales were used for evaluating the operated knee at the 12-month follow-up.

RESULTS

Differences in cartilage lesion changes observed by MRI between the two groups were statistically significant (P = 0.030 at 1 week postoperatively; P = 0.025 at 12 months postoperatively). No significant differences were evident with respect to debris residue, malalignments, nonunion, VAS, ROM and Lysholm knee scoring scale with the exception of stair climbing (P = 0.02).

CONCLUSION

Based on the data of this one-year clinical follow-up study, the SP approach using the CASS system offers the potential to benefit patients suffering from tibial shaft fractures, who will be treated with intramedullary nailing especially for smaller patients.

Intramedullary Nailing of Lower-Extremity Periarticular Fractures

Intramedullary nailing is used to stabilize distal femoral, proximal tibial, and distal tibial periarticular fractures with short proximal or distal segments, as well as some intra-articular fractures in which a stable articular block can be created. Intramedullary nailing may be beneficial in complex fracture patterns with diaphyseal extension, segmental injuries, or patients who might benefit from a decreased incision burden. Step 1: Preoperative planning. Review imaging and make sure there is a nail with adequate interlocks. Consider the use of adjunctive techniques to obtain and maintain alignment, and how intra-articular fracture lines will be stabilized. Step 2: Position and prepare the patient. Step 3: Exposure for nailing via suprapatellar, infrapatellar, or knee arthrotomy approaches. Limited exposure of fracture planes may also be necessary for adjunctive techniques. Step 4: Convert an OTA/AO C-type fracture to an A-type fracture if needed. Step 5: Obtain appropriate starting point and trajectory with the nail starting wire and use the opening reamer. Step 6: Obtain reduction, if not yet done, and pass the ball-tipped reaming wire across the fracture. Step 7: Ream while holding reduction. Step 8: Pass nail. Step 9: Verify reduction is maintained and correct if needed. Step 10: Place interlocks, preferably multiplanar, in the short segment. Create a fixed angle construct if desired and convert adjunctive techniques/provisional fixation to definitive fixation as needed. Step 11: Perform final checks. Step 12: Closure. Step 13: Postoperative plan. For extra-articular fractures, one may expect healing with maintained alignment from what was present at the case end intraoperatively in the vast majority of cases. For intra-articular fractures, development of posttraumatic arthritis is an additional concern.

Implications of three-dimensional modeling of tibia for intramedullary nail fixation: A virtual study on Asian cadaver tibia

INTRODUCTION

To determine the optimal entry point (EP) of intramedullary nail (IMN) fixation and introduce a consistent landmark for practical application by analyzing three-dimensional (3D) modeling and virtual implantation.

MATERIALS AND METHODS

A total of 104 cadaveric femurs (50 males and 54 females) underwent continuous 1.0 mm slice computed tomography (CT) scans. CT images were imported into Mimics® software to reconstruct 3D model of tibiofibular bone with medullary canal. Expert Tibial Nail (ETN®, Ø12mm/Length 315 mm) was processed into a 3D model at the actual size and optimally implanted in the tibia. After IMN was aligned in a neutral position, it was defined as a true AP projection. In the true AP projection, optimal EP and relationship with adjacent structures were assessed based on the degree of tibial rotation.

RESULTS

EP was placed eccentrically around the lateral tibial spine in cephalad view and in true AP projection in all models. In true AP projection, the overlapping point between fibular tip and cortical margin of lateral condyle was placed lateral to the fibular tip in 62 models, and exactly matched with fibular tip in 42 models. As tibia rotates, the position of EP in the AP view changes. When tibia was externally rotated, EP was located to the lateral, not the medial side of the lateraltibialspine. The obliquity of guide wire also changed withtibialrotation; the obliquity of guide wire aligned in a straight in true AP projection.

CONCLUSION

Optimal determination of EP and guide wire direction should be performed by considering the overlapping point that should be placed to just or lateral side of fibular tip in AP projection. Compared with fibular bisector line, the overlapping point is also useful as a practical landmark for making true AP projection and determining optimal EP.

Pearls and Pitfalls With Intramedullary Nailing of Proximal Tibia Fractures

Intramedullary fixation of proximal tibia fractures remains a challenging surgical technique, with malalignment reported as high as 84%. The pull from the extensor mechanism, the hamstring and iliotibial band, in addition to the lack of endosteal fit from the nail, has made surgical fixation of these fractures difficult. Commonly held principles to reduce angular deformity include ensuring adequate imaging, obtaining an optimal start and trajectory for the implant, and obtaining and maintaining a reduction throughout the duration of the procedure. Some adjunctive techniques to assist in the application of these principles include use of a semiextended technique, clamping, blocking screws/wires, and unicortical plates. Understanding the challenges involved in intramedullary nailing of proximal tibia fractures and considering a wide array of techniques in the orthopaedic surgeon's armamentarium to combat these challenges is important.

Suprapatellar Tibial Nailing

The suprapatellar nailing technique is an important adjunct in the armamentarium of an orthopedic surgeon. Although a variety of new instrumentations are required for insertion of the suprapatellar nail, most companies now carry these instruments. Easier positioning, maintenance of reduction, ease of intraoperative fluoroscopy, more anatomic starting trajectory, decreased malreduction rates, and possible decrease in anterior knee pain are all benefits of suprapatellar nailing, thus making mastery of this technique essential for an orthopedic surgeon.

Use of a Novel Tibial Traction Triangle for Intramedullary Nailing of Tibia Fractures

Malalignment after intramedullary nailing of proximal and distal tibia fractures remains a significant problem. We describe the use of a novel device to ease treatment of tibia fractures that undergo intramedullary nailing. The tibial traction triangle is simple and easy to use and allows for better reductions, leading to lower rates of malalignment. A prospective series of 11 patients is presented.

Improved Outcomes With Semi-extended Nailing of Tibial Fractures? A Systematic Review

OBJECTIVE

To systematically review the existing literature to determine whether knee pain and function following intramedullary nailing of tibial shaft fractures differs significantly by surgical technique-specifically with semi-extended nailing versus traditional infrapatellar approaches.

DATA SOURCE

A comprehensive search of PubMed/MEDLINE, EMBASE, and the Cochrane Database was conducted on August 15, 2018.

STUDY SELECTION

We included level I-level III studies that examined outcomes of tibial intramedullary nailing utilizing a semi-extended technique. All included studies reported Lysholm Knee Scores with minimum clinical follow-up of 1 year. Non-English language literature and studies older than 20 years were not included.

DATA EXTRACTION

Data from each study were independently recorded by 2 reviewers.

DATA SYNTHESIS

Two prospective, randomized trials and 4 retrospective cohort studies were included in this review. A meta-analysis was not performed.

CONCLUSIONS

Evidence comparing postoperative knee pain and functional outcomes between semi-extended and traditional infrapatellar nailing is limited. Available literature suggests satisfactory outcomes with semi-extended nailing. The highest level of evidence available does indicate improved pain and function with semi-extended nailing as compared to infrapatellar nailing. Additional research may be required to reach consensus conclusions.

LEVEL OF EVIDENCE

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

Intra-medullary nail insertion accuracy: A comparison of the infra-patellar and supra-patellar approach

AIMS

The anatomical safe zone for intra-medullary nail insertion through the tibial plateau is small, insertion outside of this area risks damage to intra-articular structures and poor fracture reduction. The purpose of this retrospective study was to determine if the new supra-patella (SP) approach confers improved nail insertion accuracy, when compared with the standard infra-patella (IP) technique.

PATIENTS AND METHODS

Two hundred cases were included in the study (SP 95, IP 105). Insertion accuracy was assessed on AP and lateral radiographic imaging, and measured as the distances between the central axis of the proximal nail and the ideal entry point.

RESULTS

The median distance from the ideal entry point was 4.4 mm (SP) and 5.1 mm (IP) (p = 0.046) in the coronal plane, and 4.0 mm (SP) and 3.7 mm (IP) (p = 0.527) in the sagittal plane. A narrower range in measurements was observed in the SP technique in both sagittal and coronal planes, 17.8 mm vs 28.6 mm, and 19.7 mm vs 30.3 mm respectively.

CONCLUSION

We found that the SP technique achieved significantly improved nail insertion accuracy in the coronal plane. Insertion accuracy was equivocal between the two techniques in the sagittal plane. A narrower range in entry points was observed in the SP cohort in both planes suggesting improved control in nail insertion using this technique.

Knee Pain and Functional Scores After Intramedullary Nailing of Tibial Shaft Fractures Using a Suprapatellar Approach

OBJECTIVES

To evaluate the effects of intramedullar nailing of the tibia using a suprapatellar (SP) approach with respect to pain and function of the knee.

DESIGN

Prospective clinical investigation.

SETTING

Academic level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-one patients with tibial shaft fractures (Orthopaedic Trauma Association 42A-B-C) with a minimum of 12-month follow-up.

INTERVENTION

Locked intramedullary nailing using a SP approach.

MAIN OUTCOME MEASUREMENTS

Radiographic evaluation for nail position proximally, tibial shaft alignment and union, anterior knee pain using the visual analog scale, and knee function evaluation using the Lysholm and SF-36 scores. Examination of intra-articular damage was performed using intraoperative patellofemoral arthroscopy before and after nail insertion.

RESULTS

The mean age of the patients was 35.4 ± 12.4 years (range, 18-63 years), and the mean follow-up period was 15.62 ± 3.2 months (range, 12-21 months). The visual analog scale score for anterior knee pain was a mean of 1.0 ± 1.3 (range, 0-4). The SF-36 physical score was mean 45.1 ± 9, and the SF-36 mental score was a mean of 51.7 ± 9.9. The knee joint range of movement was measured as 133.1 ± 87 degrees on the affected extremity side and 134.05 ± 8.4 degrees on the unaffected side. The mean Lysholm knee score was 95.76 ± 4. No intra-articular pathology was seen on arthroscopy after nail insertion.

CONCLUSIONS

The SP approach for intramedullar nailing for tibial shaft fractures was not associated with either anterior knee pain or functional limitations of the knee in our series.

LEVEL OF EVIDENCE

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

Ultrasonographic comparison of bilateral patellar tendon dimensions in patients treated via intramedullary tibial nailing using a transpatellar approach

Objective

One of the most common complications following intramedullary nailing of a tibial shaft fracture is anterior knee pain. The etiology of pain remains unclear. Patellar tendon entry point is the most suspected reason for anterior knee pain. This study, sonographically examined the patellar tendons of patients treated via intramedullary nailing.

Methods

Thirty-two patients with a tibial shaft fracture requiring intramedullary nailing via a transpatellar approach were included in the study. After all patients were grouped by reference to the presence of anterior knee pain, bilateral patellar tendon ultrasonography was performed.

Results

Thirty-two patients were included in the study. Patients were measured postop average in 38.3 months (10th months - 84th months). It was determined that 10 patients of total 32 (31.3%) had anterior knee pain. There were no statistically differences between study groups in the length of patellar tendon. In the painless group; patellar tendon was wider and thicker in the operated side than the non operated side. The mean differences in the thickness between operated side versus non – operated side of the painless group were 5.3 ± 1.8 in the operated side and 3.9 ± 1.4 in the non – operated side (p = 0.007 < 0.05). The corresponding values for width of the patellar tendon was 29.6 ± 3.3 in the operated side and 27.6 ± 3.8 in the non – operated side (p = 0.007 ˂ 0.05). As a result, there were no statistically significant differences between width and thickness of the patellar tendons in the painful group, on the contrary, in the painless group; patellar tendons were wider and thicker in the operated side than those in the non - operated side. Mean values for thickness of the operated and non-operated side were 5.9 ± 2.3 and 4.2 ± 2.0, respectively (p = 0.059 > 0.05). Mean values for width of the operated and non-operated side were 30.2 ± 4.5 and 28.5 ± 4.0, respectively (p = 0.103 > 0,05).

Conclusion

Based on the ultrasonographic investigation of their patellar tendons after intramedullary nailing of a tibial shaft fracture, in the painless patients group; the patellar tendon was wider and thicker in the operated side than the non – operated side, however, in the painful patients there were no statistically significant differences between this parameters. Although the number of patients was not sufficient to conclude precise relation between patellar tendon entry point and anterior knee pain, we determined that thicker and wider tendon might be less related to anterior knee pain.

Level of evidence

Level IV, therapeutic study.

Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series

Tibial shaft fractures are extremely common injuries. High rate of union, acceptable alignment in all planes, and a low complication rate have been reported when diaphyseal fractures are treated by intramedullary nailing. However, knee pain after tibial nailing has historically been problematic. While the exact aetiology of the knee pain is still unknown, surgical approach relative to the patellar tendon, nerve transection, violation of the fat pad or joint capsule as well as nail diameter and implant prominence have been claimed as possible causes. Therefore, establishing an appropriate starting point remains a crucial step in the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Literature is lacking on this topic, therefore the present article discusses clinical outcomes of 25 patients treated by suprapatellar nailing at 2 years follow up and a literature review.

Importance of Mechanoreceptors and Other Neural Structures Within the Anterior Intermeniscal Ligament in the Etiology of Anterior Knee Pain After Tibial Nailing

BACKGROUND

Anterior knee pain is the most common complication after intramedullary tibial nailing. The cause is often multifactorial and varies among individuals. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible source of postsurgical anterior knee pain. Although there is a certain ambiguity regarding the importance and function of the AIL, neural structures in the AIL tissue might play a significant role with respect to functional purposes and pain perception.

METHODS

We subjected 6 AIL specimens to histologic examination to identify the neural structures that are a mandatory requirement as a source of anterior knee pain. Specifically, we performed three-dimensional immunohistochemical investigation of subtyping, orientation, and detailed characterization of neural structures within the AIL tissue.

RESULTS

Histologic and three-dimensional immunohistochemical examinations confirmed the presence of neural structures in all 6 AIL specimens. We identified myelinated and unmyelinated nerve fibers, as well as all types of mechanoreceptors.

CONCLUSIONS

Free nerve endings are a mandatory requirement for pain perception as a result of AIL violation during tibial nailing. Our verification of all different types of mechanoreceptors in the AIL tissue makes a role of the ligament in knee joint function and proprioception highly probable. Further investigations are necessary to clarify possible correlations between neural supply and function of the AIL. Violation of the ligament during operative procedures should be avoided, although the significance of the AIL is still debated.

Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique

INTRODUCTION

The purpose of this study is to evaluate the intra- and inter-observer reliability of low-dose protocolled bilateral postoperative Computed Tomography (CT)-assessment of rotational malalignment after intramedullary nailing (IMN) of tibial shaft fractures.

MATERIALS AND METHODS

156 patients were prospectively included with tibial shaft fractures that were treated with IMN in a Level-I Trauma Centre. All patients underwent post-operative bilateral low-dose CT-assessment (effective dose of 0.03784 - 0.05768 mGy) as per hospital protocol. Four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. The Intra-Class Coefficient (ICC) was calculated to evaluate intra- and inter-observer reliability. The intra- and inter-observer reliability was categorized according to Landis and Koch.

RESULTS

Intra-observer reliability for quantification of rotational malalignment on post-operative CT after IMN of tibial shaft fractures was excellent with 0.95 (95% CI = 0.92-0.97). The overall inter-observer reliability was 0.90 (95% CI = 0.87-0.92), also excellent according Landis and Koch.

CONCLUSION

Firstly, bilateral post-operative low-dose -similar radiation exposure as plain chest radiographs- CT assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following IMN of tibial shaft fractures and it allows for early revision surgery. Secondly, it may contribute to our understanding of the incidence-, predictors- and clinical relevance of post-operative tibial rotational malalignment in patients treated with IMN for a tibial shaft fracture, and facilitates future studies on this topic.

Anterior intermeniscal ligament: frequency in MRI studies and spatial relationship to the entry point for intramedullary tibial nailing related to the risk of iatrogenic violation

BACKGROUND

Anterior knee pain is the most common complication after intramedullary tibial nailing. Often, the cause is multifactorial and individually different. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible origin of postsurgical anterior knee pain. Both the importance and function of the AIL remain somewhat ambivalent, and even the figures quoted in the literature for its existence in the population vary drastically. Our aim was to verify the estimated frequency of the AIL in the literature by retrospectively analysing the data of MRI studies conducted at our hospital. In addition, we attempted to assess the potential risk of AIL violation during intramedullary tibial nailing, based on the spatial arrangement.

METHODS

Two independent examiners analysed the images generated in 351 MRI studies conducted at our hospital between June 2013 and May 2014. All cases who did not reveal any previous knee-joint injury or osteoarthritis of the knee were allocated to group I. All other cases were included in group II. To estimate the potential risk of AIL injury during the nailing procedure, the distance between the AIL and the theoretical entry point for intramedullary nailing was measured.

RESULTS

We identified the AIL on the images of nearly all patients (96.5%) in group I. In group II, the presence of the AIL was confirmed in only 51.4% of cases (p < 0.001). The average distance between the AIL and theoretical entry point for intramedullary tibial nailing was 10.1 mm (range 3.48-18.88 mm).

CONCLUSIONS

Because we were able to confirm the presence of the AIL in nearly all patients without a history of knee joint injuries or osteoarthrosis, we presume that the AIL may play a role in knee joint function. Violation of the AIL during intramedullary nailing appears likely due to the close position of the AIL in relation to the entry point for the inserted nail. As a result and due to its rich sensory innervation, a connection between AIL violation during tibial nailing and postoperative onset of anterior knee pain seems likely. To eliminate one risk factor of anterior knee pain development and in view of the unresolved issues of AIL function, violation of the ligament during any operative procedure should be avoided.

Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment

Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

Intramedullary Nailing of Periarticular Fractures

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed.

Suprapatellar versus infrapatellar intramedullary nailing for treatment of tibial shaft fractures in adults

BACKGROUND

Numerous studies have compared suprapatellar (SP) nailing to infrapatellar (IP) nailing for treatment of tibial shaft fractures; however, the best strategy remains controversial. The aim of this meta-analysis is to assess whether SP or IP nailing is more effective for tibial shaft fractures in adults.

METHODS

Literature searches of PubMed, Embase, OVID, Cochrane Library, Web of Science, Chinese Biomedical Literature, Wanfang, Weipu Journal, and CNKI databases were performed up to July 2017. Only randomized controlled trials (RCTs) comparing SP versus IP intramedullary nailing for tibial shaft fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

RESULTS

Twelve RCTs were selected for analysis. SP intramedullary nailing reduced knee joint pain, visual analog score, fluoroscopy time, and sagittal angle, resulting in better Harris hip score, Lysholm knee score, short-form 36 questionnaire, range of motion, and rates of "excellent" and "good" outcome. There were no significant differences in operative time, blood loss, length of hospital stay, union time, and coronal angle between groups.

CONCLUSION

The present meta-analysis indicates that SP intramedullary nailing has obvious advantages over IP intramedullary nailing for treatment of tibial shaft fractures in adults. However, owing to the low-quality evidence currently available, additional high-quality RCTs are needed to confirm these findings.

Proper Distal Placement of Tibial Nail Improves Rate of Malalignment for Distal Tibia Fractures

OBJECTIVES

We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes, respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures.

DESIGN

Retrospective study.

LEVEL OF EVIDENCE

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

SETTING

One Level I and one Level II trauma center.

PATIENTS/PARTICIPANTS

Two hundred three distal tibia fractures treated with intramedullary nailing (IMN) (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position.

MAIN OUTCOME MEASURES

Primary malalignment ≤5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs.

RESULTS

Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (P = 0.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (P = 0.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was measured on both the anteroposterior and mortise ankle radiographs using both the plafond and talus as a reference, whereas sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane, passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint.

CONCLUSIONS

This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the anteroposterior view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, nonanatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared with nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed.

Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures

BACKGROUND

During intramedullary nailing of tibial fractures, the insertion angle of the nail is of great importance. When the nail impacts the posterior cortex due to a large insertion angle with a dorsal target course, higher insertion forces are needed, and the danger of iatrogenic fractures increases. Accordingly, the insertion direction should be as parallel as possible to the longitudinal axis of the tibia. We aimed to confirm the hypothesis that intramedullary nailing of tibial fractures can be performed with smaller insertion angles via a suprapatellar approach rather than infrapatellar approach.

METHODS

In 19 human bodies of donors with intact tibiae, we performed intramedullary nailing by both a suprapatellar and an infrapatellar approach. The correct entry point was determined by fluoroscopy. Subsequently, the medullary canal was reamed up to a diameter of 10 mm, and a 9 mm polytetrafluorethylen tube was inserted instead of a tibia nail. The angle between the proximal aspect of the tube and the longitudinal axis of the tibia was measured using a computer-assisted surgery system.

RESULTS

The angle between the proximal aspect of the inserted tube, simulating the tibial nail, and the longitudinal tibial axis was significantly larger when using the infrapatellar approach.

CONCLUSIONS

We achieved an insertion angle significantly more parallel to the longitudinal axis when using a suprapatellar approach for intramedullary nailing of tibial fractures. Thereby, both the risk of iatrogenic fracture of the posterior cortex and apex anterior angulation of the short proximal fragment can be reduced during intramedullary nailing of tibial fractures.

Insertion-related pain with intramedullary nailing

The use of intramedullary nails for the treatment of long bone fractures has become increasingly frequent over the last decade with gradually expanding indications and technological advances. Improved biomechanics relative to plates and less direct fracture exposure are some of the potential benefits of intramedullary nails. However, persistent insertion-related pain is common and may limit satisfactory long term outcomes. The etiologies of this phenomenon remain unclear. Proposed theories for which there is a growing body of supporting evidence include hardware prominence, suboptimal nail entry points leading to soft tissue irritation and structural compromise, local heterotrophic ossification, implant instability with persistent fracture micromotion, and poorly defined insertional strain. Many factors that lead to insertion-related pain are iatrogenic, and careful attention to detail and refined surgical techniques will optimize outcomes.

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

INTRODUCTION

Traditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine - STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures.

METHODOLOGY

A case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing.

RESULTS

There was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p=0.007, 130.3min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control].

CONCLUSION

Intraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.

A Concert between Biology and Biomechanics: The Influence of the Mechanical Environment on Bone Healing

In order to achieve consistent and predictable fracture healing, a broad spectrum of growth factors are required to interact with one another in a highly organized response. Critically important, the mechanical environment around the fracture site will significantly influence the way bone heals, or if it heals at all. The role of the various biological factors, the timing, and spatial relationship of their introduction, and how the mechanical environment orchestrates this activity, are all crucial aspects to consider. This review will synthesize decades of work and the acquired knowledge that has been used to develop new treatments and technologies for the regeneration and healing of bone. Moreover, it will discuss the current state of the art in experimental and clinical studies concerning the application of these mechano-biological principles to enhance bone healing, by controlling the mechanical environment under which bone regeneration takes place. This includes everything from the basic principles of fracture healing, to the influence of mechanical forces on bone regeneration, and how this knowledge has influenced current clinical practice. Finally, it will examine the efforts now being made for the integration of this research together with the findings of complementary studies in biology, tissue engineering, and regenerative medicine. By bringing together these diverse disciplines in a cohesive manner, the potential exists to enhance fracture healing and ultimately improve clinical outcomes.

Surgical approaches to intramedullary nailing of the tibia: Comparative analysis of knee pain and functional outcomes

INTRODUCTION

Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches.

METHODS

A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05.

RESULTS

Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45).

CONCLUSION

In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint.

Suprapatellar Versus Infrapatellar Tibial Nail Insertion: A Prospective Randomized Control Pilot Study

PURPOSE

The purpose of this OTA-approved pilot study was to compare the clinical and functional outcomes of the knee joint after infrapatellar (IP) versus suprapatellar (SP) tibial nail insertion.

DESIGN

Prospective, randomized.

SETTING

Level I trauma center.

METHODS

After institutional review board approval, skeletally mature patients with OTA 42 tibial shaft fractures were randomized into either an IP or SP nail insertion group after informed consent was obtained. The SP also underwent prenail and postnail insertion patella-femoral (PF) joint arthroscopy. Patients underwent follow-up (6 weeks, 3, 6, and 12 months) with standard radiographs, as well as visual analog score and pain diagram documentation. At the 6-month and 12-month visits, knee function questionnaires (Lysholm knee scale and SF-36) were completed. Magnetic resonance imaging/image (MRI) of the affected knee was obtained at 12 months. Ten patients in each group were required for a power analysis for the anticipated larger randomized control trial, but enrollment in each arm was not limited because of known problems with patient follow-up over a 12-month period.

RESULTS

A total of 41 patients/fractures were enrolled in this study. Of those, only 25 patients/fractures (14 IP, 11 SP) fully complied with and completed 12 months of follow-up. Six of 11 SP presented with articular changes (chondromalacia) in the PF joint during the preinsertion arthroscopy. Three patients displayed a change in the articular cartilage based on postnail insertion arthroscopy. At 12 months, all fractures in both groups had proceeded to union. There were no differences between the affected and unaffected knee with respect to range of motion. Functional visual analog score and Lysholm knee scores showed no significant differences between groups (P > 0.05). The SF-36v2 comparison also revealed no significant differences in the overall score, all 4 mental components, and 3/4 physical components (P > 0.05). The bodily pain component score was superior in the SP group (45 vs. 36, P = 0.035). All 11 SP patients obtained MRIs at 1 year. Five of these patients had evidence of chondromalacia on MRI. These findings did not correlate with either the prenail or postnail insertion arthroscopy. Importantly, no patient in the SP group with postnail insertion arthroscopic changes had PF joint pain at 1 year.

CONCLUSIONS

Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up. Based on this pilot study data, larger prospective trial with long-term follow-up is warranted.

LEVEL OF EVIDENCE

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

Character, Incidence, and Predictors of Knee Pain and Activity After Infrapatellar Intramedullary Nailing of an Isolated Tibia Fracture

OBJECTIVE

To study the activity and incidence of knee pain after sustaining an isolated tibia fracture treated with an infrapatellar intramedullary nail at 1 year.

DESIGN

Retrospective review of prospective cohort.

SETTING

Multicenter Academic and Community hospitals.

PATIENTS

Four hundred thirty-seven patients with an isolated tibia fracture completed a 12-month assessment on pain and self-reported activity.

INTERVENTION

Infrapatellar intramedullary nail.

OUTCOMES

Demographic information, comorbid conditions, injury characteristics, and surgical technique were recorded. Knee pain was defined on a 1-7 scale with 1 being "no pain" and 7 being a "very great deal of pain." Knee pain >4 was considered clinically significant. Patients reported if they were "able," "able with difficulty," or "unable" to perform the following activities: kneel, run, climb stairs, and walk prolonged. Variables were tested in multilevel multivariable regression analyses.

RESULTS

In knee pain, 11% of patients reported a "good deal" to a "very great deal" of pain (>4), and 52% of patients reported "no" or "very little" pain at 12 months. In activity at 12 months, 26% and 29% of patients were unable to kneel or run, respectively, and 31% and 35% of patients, respectively, stated they were able with difficulty or unable to use stairs or walk.

CONCLUSIONS

Clinically significant knee pain (>4/7) was present in 11% of patients 1 year after a tibia fracture. Of note, 31%-71% of patients had difficulty performing or were unable to perform routine daily activities of kneeling, running, and stair climbing, or walking prolonged distances.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.