Removal of interlocking intramedullary nail for relieve of knee pain after tibial fracture repair

Effect of Transverse Versus Longitudinal Incisions on Anterior Knee Pain After Tibial Nailing (TRAVEL): A Multicenter Randomized Trial with 1-Year Follow-up

BACKGROUND

Anterior knee pain is common after tibial nailing, and its origin is poorly understood. Literature suggests it may be related to infrapatellar nerve injury. The aim of this study was to compare the effect of a transverse (potentially infrapatellar nerve-sparing) incision versus a longitudinal incision for the insertion of a tibial nail with respect to anterior knee pain.

METHODS

Patients with a tibial shaft fracture undergoing treatment with use of an intramedullary nail were randomized to a transverse incision (n = 68) or longitudinal incision (n = 68) in multiple centers. The primary outcome measure was kneeling pain based on a numeric rating scale (NRS). Secondary outcome measures included knee pain during daily activities, functional outcome (Short Musculoskeletal Function Assessment and Lower Extremity Functional Scale), quality of life (EuroQol-5 Dimensions), activity resumption, complications, reoperations, and costs within 1 year after trauma.

RESULTS

At 12 months, the estimated marginal mean for kneeling pain was 2.4 (95% confidence interval [CI], 1.6 to 3.2) in the transverse incision group and 3.7 (95% CI, 3.0 to 4.5) in the longitudinal incision group. Regression analysis showed no significant difference between the groups over time. Knee pain scores for daily activities, functional outcome scores, and quality of life were also comparable between the groups. Signs of infrapatellar nerve injury were found less often after a transverse incision (18% versus 54%; p < 0.001). The median total (direct and indirect) costs per patient were €10,468 in the transverse incision group and €11,066 in the longitudinal incision group. Loss of productivity accounted for 67% and 52% of the total costs in the 2 groups, respectively.

CONCLUSIONS

A transverse incision reduces injury to the infrapatellar nerve, but anterior knee pain scores and function are comparable after use of a transverse or longitudinal incision for tibial nail insertion.

LEVEL OF EVIDENCE

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

Evaluation of the Functional and Radiological Outcomes of Antibiotic-Coated Intramedullary Interlocking Nailing for Gustilo and Anderson Grades 2 and 3 Open Tibial Shaft Fractures

Background: Tibial shaft fractures are the most common fractures among long bones. At present, implants coated with broad-spectrum antibiotics have been developed, and antimicrobial eluting implants are widely used in clinical practice.

Materials and methods: This prospective study was conducted among 40 patients with tibial shaft fractures who visited the Department of Orthopedics in RL Jalappa Hospital, Tamaka, Kolar, Karnataka, from February 2021 to September 2021. As it is a large trauma center near the national highway, all 40 cases, including the referral cases, were operated within two months of the initiation of the study, with the last case operated in March 2021. The inclusion criteria were: patients aged more than 18 years, diaphyseal tibial fractures definitively treated by antibiotic coated intramedullary nailing, and Gustilo and Anderson grades 2, 3A, and 3B open tibial shaft fractures. All patients with grades 2, 3A, and 3B open fractures of the tibial shaft were treated with antibiotic-coated nails and followed up at one, three, and six months post-surgery.

Results: The mean age of patients was 35.6 years, and the mean union time of fractures was 4.2 months. Road traffic accidents (RTA) are the most common etiology for tibial bone fractures. In this study, grade 3A open fractures had the highest number of cases (N = 26). No patients in the present study developed superficial or deep infections post-operatively. All patients were assessed with Johner-Wruhs criteria at each follow-up, and they showed improvement in knee and ankle joint mobility, pain, and deformity. Most patients achieved good functional results after postoperative follow-up, followed by those with excellent results. According to the radiographic union scale in tibial shaft fractures criteria, 23 patients showed good radiological results after postoperative follow-up, followed by 15 patients with excellent and 2 patients with fair results.

Conclusion: Most of the patients showed good to excellent functional and radiological results according to Johner-Wruhs and Radiographic Union Scale for Tibial fractures (RUST) criteria. The use of antibiotic-coated nails to treat compound tibial fractures was associated with a decreased risk of deep wound infections and good fracture healing.

Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE)

Background

Intramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals.

Materials and methods

We performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included.

Result

A total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication.

Conclusion and clinical significance

This study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails.

How to cite this article

Frost MW, Kold S, Rahbek O, et al. Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE). Strategies Trauma Limb Reconstr 2021;16(2):110-115.

Repetitive brief ischemia accelerates tibial shaft fracture healing: a 5-years prospective preliminary clinical trial (PCT)

BACKGROUND

This study was to evaluate the effects of repetitive brief ischemia (RBI) on bone healing in patients with tibial shaft fractures.

METHODS

In this prospective clinical trial, patients with tibia shaft fractures were enrolled between January 2016 and January 2021. The intermittent pneumatic compression (IPC) device was used to make RBI on the affected limb after surgical operation 24 h. The inflation pressure was the systolic pressure of patients + 50 mmHg. Patients were received 30 s inflation/30 s deflation 30 times twice a day for 4 weeks. The primary outcome was bone healing time and the secondary outcomes were the rates of delayed union and nonunion, the rates of venous thrombosis of lower limbs, Johner-Wruhs scores, Lysholm knee score, VAS scores, postoperative complications, serum BMP-2, osteocalcin (OC) and bone specific alkaline phosphatase (BS-ALP).

RESULTS

A total of 32 patients were enrolled finally and all were completed with a 12 months follow-up. All the fractures were healed and the bone healing time was 3(1) months in RBI group. However, the bone healing time of control group was 4(1) and there was statistical difference between the two groups (p < 0.01). No patient with fracture delayed union, nonunion and venous thrombosis of lower limbs in RBI group. 2 patients were delayed union in the control group. In RBI group, the Lysholm knee score was 83(6) at 6 months and 100(8) at 12 months. In the control group, the score was 78(4) and 90.5(17), there was statistical difference between the two groups (p < 0.01, p = 0.014, respectively). VAS scores were postoperative 2 weeks 6(1) in RBI group and 7(0.5) in the control group, there was statistical difference between the two groups (p = 0.016). There were 2 patients with intramuscular venous thrombosis of lower extremity in control group. Besides, RBI treatment increased the serum BMP-2, OC and BS-ALP at postoperative 2 weeks and 1 month.

CONCLUSIONS

RBI is a new method to accelerate bone healing in tibia shaft fracture patients and is a simple and noninvasive method.

TRIAL REGISTRATION

Chinese clinical trial registry, ChiCTR-INR-17014208 . Registered 28 December 2017-Retrospectively registered.

A comparison of anterior knee pain, kneeling pain and functional outcomes in suprapatellar versus infrapatellar tibial nailing

INTRODUCTION

Anterior knee pain and kneeling pain are some of the most common complications following intramedullary nailing of tibial shaft fractures. With the increased uptake of suprapatellar nailing at our institution, we undertook a service evaluation to assess anterior knee pain and kneeling pain in patients who underwent the suprapatellar tibial nailing technique compared with the infrapatellar approach.

METHODOLOGY

Data from all consecutive intramedullary tibial nailing operations between January 2014 and July 2017 were analysed from a prospectively collected database. All acute diaphyseal fracture nailing procedures were included. All patients were reviewed between six-month and four-year post-operation. Each patient was asked to complete a standardised questionnaire with three main outcome measures: pain on kneeling, presence of anterior knee pain and the severity of pain.

RESULTS

After exclusions, a total of 148 patients were identified. A total of 102 responses were received, 41 in the infrapatellar group (73.2%) and 61 in the suprapatellar group (66.3%). A longer time from surgery to telephone follow-up response was noted in the infrapatellar group: 32.4 months (interquartile range, 16.1) vs. 19.3 months (interquartile range, 17.4), p < 0.001. A trend towards lower reported anterior knee pain was noted in the suprapatellar group (67.9% VS 53.7%). Most patients reported mild or no pain on kneeling, with no significant difference between the two groups. There was also no significant difference in severity of knee pain between the two groups and no significant effect on the Kujala score.

CONCLUSION

With the comparable pain outcomes between the two groups, our analysis supports the continued use of the suprapatellar tibial nailing technique for tibial shaft fractures at our institution.

Intramedullary nailing through a suprapatellar approach. Evaluation of clinical outcome after removal of the device using the infrapatellar approach

Background and aim of the work: Since 2006, It has been developed the possibility to introduce a tibia nail through a suprapatellar access. However, the removal of device must be carried out using the classic infrapatellar approach. The aim of this study is to evaluate the clinical scores of a group of patients that removed a tibial nail by infrapatellar approach, previously introduced through a suprapatellar access. Methods: Seven patients received removal, through infrapatellar access, of tibial nail previously introduced by suprapatellar approach. Despite being VAS <5, patients requested the device to be removed. The variables studied were the distance between the apex of the nail and the tibial plateau (TPD) and between the apex of the nail and the anterior tibia (ATD), oxford knee score (OKS), Kujala score (KJS), Visual Analog Scale (VAS) and SF 36 before surgery and 1 year. A1 year of follow up the Sidky-Buckley questionnaire was administered. The follow-up was 1 year. Results: The mean VAS was 2.8 before surgery and 0.5 at 1 year after surgery, OKS average pre-surgery is 38 (good), while at 1 year it becomes 44 (excellent). The Sidky-Buckley questionnaire showed that all patients would have the intramedullary nail removed again. The widest improvement in all parameters is seen in the two patients with less distance from the tibial plateau. Conclusions: Although the patients had received initial suprapatellar access and a second infrapatellar for the removal of the device, no complications were reported regarding the use of the two accesses. (www.actabiomedica.it)