Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia

Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials

BACKGROUND

Intramedullary nail (IMN) and plate fixation are the most commonly used surgical modalities for distal tibia fractures. However, the superiority of their efficacy regarding functional outcomes and complications remains controversial. Here, we performed a systematic review and meta-analysis to compare the efficacy of these two modalities.

METHODS

Randomized controlled trials (RCTs) comparing the efficacy of IMN and plate fixation in distal tibia fractures were searched in PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Library up to January 31, 2024. Weighted mean difference (WMD) and odds ratio (OR) with corresponding 95% confidence interval (CI) were estimated using a random-effect model for continuous and categorical outcomes, respectively.

RESULTS

A total of 20 RCTs comprising 1528 patients were included. Compared with plate fixation, IMN significantly shortened surgery time (WMD=-10.73 min, 95%CI: -15.93 to -5.52), union time (WMD=-1.56 weeks, 95%CI: -2.82 to -0.30), and partial (WMD=-1.71 weeks, 95%CI: -1.91 to -0.43) and full (WMD=-2.61 weeks, 95%CI: -3.53 to -1.70) weight-bearing time. IMN was associated with markedly reduced risk of wound infection (OR = 0.44, 95%CI: 0.31-0.63) and secondary procedures (OR = 0.72, 95%CI: 0.55-0.95), but increased the risk of malunion (OR = 1.53, 95%CI: 1.02-2.30) and anterior knee pain (OR = 3.94, 95%CI: 1.68-9.28). The rates of nonunion, delayed union, and functional assessment scores did not significantly differ between the two groups. The percentages of patients obtaining an excellent functional outcome or an excellent and good functional outcome post-operation were comparable.

CONCLUSIONS

Both IMN and plate fixation are effective modalities for the surgical treatment of distal tibia fractures. IMN seems to be preferred since it confers more advantages, but the elevated rates of malunion and knee pain require attention. The decision on fixation modality should be tailored to the specific fracture, considering these pros and cons.

Chronic knee pain following infrapatellar/suprapatellar magnetic intramedullary lengthening nails versus external fixators in limb length discrepancy: A retrospective review

Aims & objectives

Prior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation.

Materials & methods

We reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP.

Results

Mean LKSS was 96.3 for external fixation and 88.5 for MILN (P = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes.

Conclusion

Tibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted.

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.

Outcomes and their predictors in suprapatellar nailing for tibia fractures. Multivariable analysis of 293 consecutive cases

PURPOSE

Intramedullary nailing of tibial fractures is one of the most common procedures in orthopedic surgery. It can be technically demanding in proximal or distal fractures, which may be facilitated using semi-extended approaches. The aim of this study is to identify outcomes and their predictors using a semi-extended suprapatellar approach for tibial fracture nailing.

METHODS

This is a retrospective cohort of 293 patients who underwent intramedullary nail fixation of a tibial fracture through a suprapatellar approach, considering a postoperative follow-up of 1 year. Data on patient's baseline characteristics, injuries, treatments, and outcomes regarding alignment, fracture union, and complications were recorded. For multivariable analysis, hierarchical binary (logistic) regression analysis was performed.

RESULTS

The mean patient age was 47.7 years (SD 18.9), with 42A1 the most frequent fracture pattern (n = 98, 33.5%). Correct or anatomical alignment (≤ 5º in both planes) was achieved in 272 (92.8%) of the patients. On multivariate analysis, surgical delay ≥ 7 days (OR = 1.3, 95% CI = 1.3-8.1) and age over 50 years (OR = 3.2, 95% CI = 1.2-8.3) were found as predictors of fracture malalignment. Fracture healing was achieved in 97.6%, and reoperation rate was 6.14%. Overall complication's predictors were proximal fracture (OR = 2.8, 95% CI = 1.1-7.2), temporary external fixation (OR = 2.4, 95% CI = 1.2-4.9), and fracture malalignment (OR = 2.9, 95% CI = 1.1-7.9).

CONCLUSION

The suprapatellar approach is a safe and useful technique for treating tibial fractures, leading to no less than correct reduction in almost all patients and achieving a high fracture healing rate, at very low rates of complications. Pre- and postoperative predictors identified must be taken into account to improve outcomes while treating these fractures.

Is there a trend towards semi-extended knee positioning during intramedullary tibial nailing in Latin America? A survey among 990 orthopaedic surgeons

OBJECTIVE

The aim of this study was to evaluate the Latin American orthopaedic trauma surgeons preference regarding knee positioning and entry portals for IM nailing and identify the reasons of these preferences.

METHODS

Using the AO Trauma database, 22.285 surveys were distributed by email to Latin American orthopaedic surgeons. Demographic data and practice patterns, especially regarding knee positioning and approach for tibial nailing, were then evaluated and statistically treated.

RESULTS

amongst one thousand five hundred fourteen responses, 990 orthopaedic surgeons (4.4% of response rate) fully responded to the survey. Transpatellar tendon approach (613 / 61.9%,) with the knee in flexion (518 / 52.3%) on a radiolucent table remains the standard practice for intramedullary tibial nailing. Even for proximal and distal tibial nailing, the transpatellar tendon approach (455 / 46%) with the knee in flexion (562 / 56.8%) hold on the most used method. Only 55 (9.36%) orthopaedic surgeons reported that they have migrated to the supra-patellar tibial nailing in the recent years. The main reasons for a low rate of migration were lack of knowledge about the technique and unavailability of specific gigs and cartilage protectors for a safe suprapatellar nailing.

CONCLUSION

Even with the potential benefits of the semi-extended knee positioning for tibial nailing, the Latin American orthopaedic community remains using the transpatellar tendon approach with the knee in flexion as the standard technique. Lack of surgical training for suprapatellar and parapatellar approaches with the knee in semi-extension, added by the unavailability of suprapatellar jigs and soft outer protection sleeves contribute to counter the trend towards the semi-extended techniques.

Arthroscopically Assisted Suprapatellar Tibial Nail Removal

Intramedullary nailing remains the most popular and preferred method of fixation for tibial shaft fractures. The infrapatellar approach through the patellar tendon has long been considered the gold standard. However, the suprapatellar approach has gained popularity because of the advantages of being easier to perform when treating proximal shaft and metaphyseal fractures and there being less postoperative anterior knee pain. Despite increased use of this approach, the removal of the implant from the same suprapatellar approach is tricky, and in most cases, the removal is performed through a new transpatellar tendon approach. This article describes arthroscopically assisted suprapatellar tibial nail removal using the same approach and instrumentation of the nail insertion. The technique has the advantage of preserving the patellar tendon without causing secondary damage to it. Through arthroscopy, direct visualization of the patellofemoral joint aids in preventing possible cartilage injury. Moreover, any associated intra-articular lesions can be diagnosed and addressed.

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.

Intramedullary Nail Fixation by Suprapatellar and Infrapatellar Approaches for Treatment of Distal Tibial Fractures

Objective

To compare the functional and alignment outcomes of intramedullary nail fixation using suprapatellar and infrapatellar approaches in treating distal tibial fractures.

Methods

In this retrospective study, 132 patients with distal tibial fractures (87 men, 45 women) ranging in age from 20 to 66 years were treated with intramedullary nails using the suprapatellar (69 patients) or infrapatellar (63 patients) approach. The radiographic alignment outcomes and ankle function were compared between the two groups. Multivariate logistic regression analyses were performed to determine which variety influenced ankle functional scores and whether the suprapatellar approach intervention demonstrated a protective effect.

Results

The mean follow‐up time was 14.22 ± 2.31 months. The mean sagittal section angle of the fracture in the suprapatellar and infrapatellar approach groups was 3.20° ± 1.20° and 5.31° ± 1.23°, respectively (P < 0.001). The mean coronal section angle was 3.51° ± 0.89° and 5.42° ± 1.05°, respectively (P < 0.001). Three patients (4.3%) in the suprapatellar approach group and 15 patients (23.8%) in the infrapatellar approach group had poor fracture reduction (P < 0.001). The mean hind foot functional score and ankle pain score were 95.91 ± 4.70 and 35.91 ± 4.70 points, respectively, in the suprapatellar approach group and 85.20 ± 5.61 and 25.20 ± 5.61 points, respectively, in the infrapatellar approach group (P < 0.001 for both). In the comparison of ankle function, the multivariate logistic regression analyses demonstrated that the odds ratio in the suprapatellar approach group was about 7 times that in the infrapatellar approach group (odds ratio, 7.574; 95% confidence interval, 2.148–28.740; P = 0.002). Of the variants measured, the statistically significant risk factors for poor ankle function were AO type A3 (P = 0.016) and diabetes mellitus (P = 0.006). Sex and the operation interval were not statistically significant risk factors for poor ankle function.

Conclusion

Intramedullary nailing using the suprapatellar approach facilitates simple fracture reduction, excellent postoperative fracture alignment, and few complications, giving it obvious advantages over the conventional infrapatellar approach. Additionally, the suprapatellar approach is a prognostic factor associated with postoperative ankle joint function.

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.

Investigating and defining outcomes of suprapatellar versus infrapatellar intramedullary nailing of tibial shaft fractures: a protocol for a pilot randomised controlled trial

Background

Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures.

Methods

This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery.

Discussion

This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing.

Trial registration

This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909.

Suprapatellar versus infrapatellar approach for intramedullary nail fixation of tibial shaft fractures: a review of the literature

Semi-extended suprapatellar intramedullary nail fixation of tibial fractures has recently been gaining popularity. Several recent studies and meta-analyses compare the outcomes of the suprapatellar approach with the traditional infrapatellar approach. Despite concerns with intra-articular placement of instruments, studies show the suprapatellar approach to be a safe alternative. Several articles conclude that the suprapatellar approach may be superior to the infrapatellar approach. This review discusses recent findings comparing suprapatellar and infrapatellar approaches for nail insertion.

Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage

AIM

Intramedullary nailing (IMN) is widely accepted as the treatment of choice for tibial fractures, and a suprapatellar method has been described to prevent common problems associated with the typical infrapatellar IMN technique, such as anterior knee pain. However, in the suprapatellar technique, injury to intra-articular structures is a concern. The aim of this study was to compare the clinical and radiological results of suprapatellar and infrapatellar IMN in terms of union, complications, and function.

METHODS

A retrospective evaluation of 61 patients who had undergone suprapatellar (n = 29, Group A) or infrapatellar (n = 31, Group B) tibial IMN was conducted. For the suprapatellar group, magnetic resonance imaging scans were acquired on the sixth month follow-up. Complications, radiological findings, functional outcomes, surgery duration, and differences in a range of motion (ROM) were compared.

RESULTS

Surgery duration was significantly shorter in Group A (81 mins vs. 107 mins, p < 0.001), and visual analog scale (VAS) values were significantly higher in Group B (0.17 vs. 1.62, p < 0.001). In Group A, the patients' Lysholm scores were significantly higher (95.6 vs. 92, p=0.006). In terms of anterior knee pain, none was experienced in Group A (0%), while 11 patients (26.1%) reported about it in Group B. There were no statistically significant differences between the two groups in SF-36 score (p=0.925), the radiographic union scale in tibial (RUST) fractures score (p=0.454), union time (p=0.110), or ROM (p=0.691). In Group A, two cases of patellofemoral cartilage degeneration were observed.

CONCLUSION

If performed with sufficient expertise, the suprapatellar IMN technique is a safe, reliable technique with a low frequency of anterior knee pain for treating tibial fractures. There is no clear evidence that it causes damage to intra-articular structures. The possibility of patellofemoral cartilage degeneration due to this technique should be further evaluated by prospective studies including pre- and postoperative radiologic assessments.

Comparison of clinical efficacy of suprapatellar and infrapatellar intramedullary nailing in treating tibial shaft fractures

Objectives:

To compare clinical efficacies of suprapatellar and infrapatellar intramedullary nailing approaches in treating tibial shaft fractures.

Methods:

Patients (n=110) admitted with tibial shaft fractures in our hospital from January 2017 to June 2020, who underwent procedures with internal fixation intramedullary nails, were retrospectively divided into suprapatellar and infrapatellar approach groups (n = 55 each) based on the surgical method used for fracture repair. The clinical and functional outcomes of the knee were assessed six months after the surgery

Results:

Six months after the operation, the pooled value for excellent and good efficacy rates in the suprapatellar approach group, as indicated by Hospital for Special Surgery (HSS) Knee scoring system, was 90.91%, which was significantly higher than that in the infrapatellar approach group (76.36%). The degree of pain (visual analogue scale (VAS) score) of the patients in the suprapatellar approach group was over 2-fold lower than in the infrapatellar approach group (P < 0.001).The Lysholm knee score, range of motion (ROM), SF-36p, and SF-36M scores in the suprapatellar approach group were significantly higher than those in the infrapatellar approach group (P < 0.001).

Conclusion:

Suprapatellar approach had significantly higher clinical efficiency than infrapatellar approach, and can significantly reduce the degree of pain, promote the recovery of patients with knee joint involvement, improve the physical and psychological well-being, reduce the number of cases of postoperative delayed healing

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.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients

BACKGROUND

Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores).

METHODS

A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.

RESULTS

A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union.

CONCLUSION

Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

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.

Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis

BACKGROUND

Intramedullary nailing (IMN) is a conventional technique for the treatment of tibial shaft fractures. It has been suggested that the suprapatellar (SP) approach holds advantages over the traditional infrapatellar (IP) approach. Current literature lacks adequate data to provide robust clinical recommendations. This meta-analysis aims to determine the efficacy of infrapatellar versus suprapatellar techniques for IMN.

METHODS

An up-to-date literature search of the Embase, Medline, and registry platform databases was performed. The search was conducted using a predesigned search strategy and all eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. Fluoroscopy time, operative time, pain score, knee function, deep infection, non-union and secondary operation rates were all considered.

CONCLUSION

A total of twelve studies were included in the meta-analysis. The results of this analysis show that suprapatellar nailing is associated with reduced post-operative pain scores and improved functional outcomes. The data suggest no significant difference in terms of operative times, fluoroscopy times, rates of deep infection, non-union or secondary procedures when compared to infra-patellar techniques. Further studies are required to confirm these findings and assess long-term results.

Toward Understanding Movement-evoked Pain (MEP) and its Measurement: A Scoping Review

OBJECTIVE

Individuals with chronic pain conditions often report movement as exacerbating pain. An increasing number of researchers and clinicians have recognized the importance of measuring and distinguishing between movement-evoked pain (MEP) and pain at rest as an outcome. This scoping review maps the literature and describes MEP measurement techniques.

MATERIALS AND METHODS

The scoping review utilized 6 databases to identify original studies that targeted pain or movement-related outcomes. Our search returned 7322 articles that were screened by title and abstract by 2 reviewers. The inclusion criteria focused on the measurement of MEP before, during, and after movement tasks in adults with chronic pain. Studies of children below 18 years of age or with nonhuman animals, case studies, qualitative studies, book chapters, cancer-related pain, non-English language, and abstracts with no full publish text were excluded from the study.

RESULTS

Results from 38 studies revealed great variation in the measurement of MEP, while almost all of the studies did not provide an explicit conceptual or operational definition for MEP. In addition, studies collectively illuminated differences in MEP compared with rest pain, movement provocation methods, and pain intensity as the primary outcome.

DISCUSSION

These results have clinically significant and research implications. To advance the study of MEP, we offer that consistent terminology, standardized measurement (appropriate for pain type/population), and clear methodological processes be provided in research publications. On the basis of the findings, we have put forth a preliminary definition of MEP that may benefit from the continued scholarly dialog.

Tibial intramedullary nailing in the lateral decubitus position: Technical notes and preliminary clinical outcomes

BACKGROUND

Traditional intramedullary nailing (IMN) for tibial shaft fractures through an infrapatellar approach is typically performed in the supine position and requires a specially designed operative table and an experienced assistant throughout the surgery. We attempted to perform IMN for tibial fractures in the lateral decubitus position to make the process easier both for surgeons and radiographers.

METHODS

A total of 36 tibial IMN procedures were performed with the patient in the lateral position from May 1, 2014 to April 30, 2016. The technical feasibility and early results were evaluated.

RESULTS

The mean time to complete the nailing procedure during surgery was 78.4 ± 1.1 min. The mean intraoperative time for fluoroscopy was 36.7 ± 1.1 min. No radiographic angular malalignment or bone non-union was reported. No surgical site infections or other surgery-related complications occurred in our series.

CONCLUSION

Tibial IMN through an infrapatellar approach in the lateral decubitus position may be a valuable alternative as it simplifies the procedure for both surgeons and radiographers. This technique is highly effective for surgical operation and fluoroscopy compared to traditional supine position. This technique also seems to provide satisfactory clinical and radiographic outcomes in our preliminary clinical outcomes.

Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients

BACKGROUND

Intramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures.

METHODS

Trip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics.

RESULTS

Fifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively.

DISCUSSION & CONCLUSION

Patients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.

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.