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Li X, Chen K, Xue H, Cheng J, Yu X. Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2024; 19:403. [PMID: 38997735 PMCID: PMC11241967 DOI: 10.1186/s13018-024-04900-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
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.
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Affiliation(s)
- Xiaobin Li
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Kaipeng Chen
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Haipeng Xue
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Junwen Cheng
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Xiaoping Yu
- Department of Clinical Laboratory, Yuncheng Central Hospital affiliated to Shanxi Medical University, No. 3690, Hedong East Street, Yanhu District, Yuncheng, Shanxi Province, 044000, China.
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Hlukha LP, Sax OC, Kowalewski KA, Bains SS, Dubin J, Herzenberg JE, Assayag MJ, McClure PK. Chronic knee pain following infrapatellar/suprapatellar magnetic intramedullary lengthening nails versus external fixators in limb length discrepancy: A retrospective review. J Orthop 2024; 51:7-11. [PMID: 38299066 PMCID: PMC10825912 DOI: 10.1016/j.jor.2023.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 02/02/2024] Open
Abstract
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.
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Affiliation(s)
- Larysa P. Hlukha
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Oliver C. Sax
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Kyle A. Kowalewski
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Sandeep S. Bains
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Jeremy Dubin
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - John E. Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Michael J. Assayag
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
| | - Philip K. McClure
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 W. Belvedere Ave., Baltimore, MD, 21215, USA
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van de Pol GJ, Axelrod DE, Conyard C, Tetsworth KD. A Suprapatellar Approach, When Compared With an Infrapatellar Approach, Yields Less Anterior Knee Pain and Better Patellofemoral Joint Function, for Intramedullary Nailing of Diaphyseal Tibial Fractures: Results of a Randomized Controlled Trial. J Orthop Trauma 2024; 38:235-239. [PMID: 38345356 DOI: 10.1097/bot.0000000000002783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To assess if a suprapatellar (SP) approach, when compared with an infrapatellar (IP) approach, yielded less patient-reported anterior knee pain and higher patellofemoral joint function at 6 weeks and 12 months postoperatively, when treating tibial fractures with intramedullary nailing. METHODS DESIGN Prospective, parallel-group randomized control trial. SETTING Tertiary level 1 trauma care center, Brisbane, Australia. PATIENTS SELECTION CRITERIA Skeletally mature patients with an acute diaphyseal tibial fracture (AO/OTA 41A2/3, 42 A1-43A3) amenable to an intramedullary nailing were included. Exclusion criteria were periprosthetic fractures, nonunions, and presence of a contralateral injury that would restrict weight-bearing. OUTCOME MEASURES AND COMPARISONS Anterior knee pain through the visual analog scale (VAS) and patellofemoral function using the Kujala scale at 6 weeks and 12 months were compared between those treated with a SP and IP approach. RESULTS Ninety-five tibia fractures were included in the randomized trial, with complete follow-up data for 44 and 46 tibia fractures in the SP and IP groups, respectively. The SP cohort exhibited better patellofemoral knee function at both 6 weeks (Kajula 53.0 for SP vs. 43.2 for IP, P < 0.01) and 12 months (Kujala 92.0 for SP vs. 81.3 for IP, P < 0.01) postoperatively and a reduction in anterior knee pain at 12 months postoperatively (VAS 0.7 SP vs. 2.9 IP, P < 0.01). CONCLUSIONS This randomized trial demonstrated clinically meaningful differences in patellofemoral function, for a SP versus IP approach, with a greater than 10 point discrepancy in Kujala score at both 6 weeks and 12 months. In addition, there was a clinically important difference in VAS knee pain scores for patients at 12 months, but not at 6 weeks, postoperatively. These results contribute to the growing body of evidence demonstrating the functional and clinical benefits of the SP approach. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gerrit J van de Pol
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Daniel E Axelrod
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Christopher Conyard
- Department of Orthopaedic Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia ; and
| | - Kevin D Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Department of Orthopaedic Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia ; and
- Orthopaedic Research Centre of Australia, Brisbane, Australia
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Wang Z, Xiong X, Lu Z, Gao Y. A systematic review and meta-analysis comparing suprapatellar versus infrapatellar approach intramedullary nailing for tibal shaft fractures. Eur J Trauma Emerg Surg 2024; 50:383-394. [PMID: 37989960 PMCID: PMC11035435 DOI: 10.1007/s00068-023-02384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 10/17/2023] [Indexed: 11/23/2023]
Abstract
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.
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Affiliation(s)
- Zhongqing Wang
- The First Clinical School of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Xianmei Xiong
- The First Clinical School of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Zesheng Lu
- The First Clinical School of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Yijia Gao
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China.
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DeCoster TA. Suprapatellar Nail Insertion for Tibial Shaft Fractures: Better Radiographic Results, But Are They Clinically Relevant?: Commentary on an article by Navnit S. Makaram, MSc, MRCS(Ed), et al.: "Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures. Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function". J Bone Joint Surg Am 2024; 106:e13. [PMID: 38446185 DOI: 10.2106/jbjs.23.01246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
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Makaram NS, Sheppard J, Leow JM, Oliver WM, Keating JF. Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function. J Bone Joint Surg Am 2024; 106:397-406. [PMID: 38100599 DOI: 10.2106/jbjs.23.00421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
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.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - James Sheppard
- University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom
| | - Jun M Leow
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - John F Keating
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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7
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Ideler N, Brauns J, Vandesande W. Suprapatellar tibial nailing: intraoperative arthroscopic evaluation and results at a minimum of 12 months follow-up. Acta Orthop Belg 2024; 90:90-95. [PMID: 38669656 DOI: 10.52628/90.1.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
To arthroscopically evaluate the intra-articular structures before and after placement of an intramedullary tibial nail using the suprapatellar approach and to assess the 1-year results. All patients with a tibial fracture that underwent intramedullary tibial nailing using the suprapatellar approach with a minimal follow-up of 12 months were included. Diagnostic intraoperative knee arthroscopy was performed before and immediately after insertion of the IMN. A radiological and clinical evaluation and VAS score of the patients was collected postoperatively. In total, 36 patients were included. The mean follow-up period was 14.9 ± 4.9 months. The mean age of the patients was 45.5 ± 18.8 years. The mean visual analog scale (VAS) score at 12 months was 1.0 ± 1.5. The complication rate was 19.4% and the reoperation rate was 16.7%. Union of the fractures was achieved in 33 patients (91.6%) after primary surgery after a mean of 6.1 ± 1.8 months. A change in the patellofemoral cartilage after insertion of the nail was seen in 1 patient. The suprapatellar procedure for tibia fractures resulted in excellent VAS scores and union rates at 1-year follow up, with a complication of articular damage to the PF joint in 2.8%.
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8
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Chen J, Wu L, Zhao H, Xue D. Comparison of suprapatellar versus infrapatellar approach for intramedullary nailing of the tibia shaft fractures: A systematic review and meta-analysis. Asian J Surg 2023; 46:5270-5271. [PMID: 37479660 DOI: 10.1016/j.asjsur.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Affiliation(s)
- Jie Chen
- Department of Orthopedics, Siyang Hospital of Traditional Chinese Medicine, Siyang, Jiangsu, 223700, China.
| | - Liwei Wu
- Department of Orthopedics, Siyang Hospital of Traditional Chinese Medicine, Siyang, Jiangsu, 223700, China
| | - Hao Zhao
- Department of Orthopedics, Siyang Hospital of Traditional Chinese Medicine, Siyang, Jiangsu, 223700, China
| | - Dong Xue
- Department of Orthopedics, Siyang Hospital of Traditional Chinese Medicine, Siyang, Jiangsu, 223700, China
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Choudri MJ, Hussain S, Bleibleh S, Remtulla M, Karthikeyan R, Cooper J. Semi-extended extra-synovial (SEES) tibial intramedullary nailing technique: Up to 10 year retrospective analysis of outcomes and anterior knee pain rates. J Clin Orthop Trauma 2023; 45:102274. [PMID: 37994353 PMCID: PMC10660984 DOI: 10.1016/j.jcot.2023.102274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/21/2023] [Indexed: 11/24/2023] Open
Abstract
Background Tibial intramedullary nailing is a common method of fixation for fractures of the tibia, with several approaches described. Anterior knee pain is a common complication following nailing, but the reported incidence of knee pain varies in the literature between 10 % and 86 %. There is considerable variation in incidence between nailing techniques, with an exact aetiology still unknown. We investigated the reported incidence of anterior knee pain in patients undergoing tibial nailing using the semi-extended extra synovial (SEES) technique at a Major Trauma Centre (MTC) in the UK. Methods A retrospective review of tibial fractures treated with the SEES technique between December 2012 to February 2021. Data collected included patient demographics, mechanism of injury, fracture characteristics, length of stay, union rates and re-operation rates. Primary outcomes were anterior knee pain rates and patient reported outcome measures (PROM), the Kujala Score. Secondary outcomes were rates of union and complications. Results 55 fractures were identified in 53 patients. Male: Female ratio was 32:21. The average age was 45.5 years. 96 % were unilateral fractures; with 53 % being right-sided. 21(38 %) fractures were open. Prior to definitive nailing 21 fractures had temporary stabilisation with an external fixator (Ex-Fix) ± wound debridement whilst the rest received plaster backslab immobilisation. 13 of the open fractures required soft tissue cover. 75 % of patients had initial surgery (SEES Nailing/Ex-Fix) within 4 days. There was a 91 % union rate with a median time to full radiographic union of 14 months. One post-operative complication of wound dehiscence was recorded. The mean follow-up time was 13.6 months. 15 % of patients reported anterior knee pain in the postoperative follow-up period. The average Kujala PROM score was 85 (Range: 52-100). Conclusion/findings The SEES technique had favourable PROM scores and displayed a lower incidence of anterior knee pain than the traditional infrapatellar approach. Knee pain rates were comparable to suprapatellar approaches without violating the knee joint. Disclosures None.
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Affiliation(s)
| | - Shakir Hussain
- University Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, United Kingdom
| | - Sabri Bleibleh
- University Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, United Kingdom
| | | | | | - Julian Cooper
- University Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, United Kingdom
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Coelho A, Sánchez-Soler JF, Fernández-Dominguez JM, Amorim-Barbosa T, Torres-Claramunt R, Perelli S, Monllau JC. Arthroscopically Assisted Suprapatellar Tibial Nail Removal. Arthrosc Tech 2023; 12:e1329-e1333. [PMID: 37654875 PMCID: PMC10466188 DOI: 10.1016/j.eats.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/29/2023] [Indexed: 09/02/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandre Coelho
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Francisco Sánchez-Soler
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Tiago Amorim-Barbosa
- Orthopedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Raúl Torres-Claramunt
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Simone Perelli
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Monllau
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
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11
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Joshi N, Deshkmukh S, Shewale Y. A Comparison of the Outcomes Between Suprapatellar and Infrapatellar Approaches of Intramedullary Interlock Nailing in Patients With Extra-Articular Tibial Fractures. Cureus 2023; 15:e40108. [PMID: 37425513 PMCID: PMC10329201 DOI: 10.7759/cureus.40108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
Background and objective Intramedullary nailing can be considered the current gold standard for the treatment of diaphyseal tibial fractures. Nailing ensures good fracture stability, protection against malalignment, and quick mobilization. The suprapatellar (SP) approach of tibial nailing in the semi-extended position has recently been recommended as a safe and effective surgical technique; it has been gaining significant attention in the orthopedic literature, with fewer complications and reoperations. The approach has been shown to facilitate a reduction in fractures around the knee joint in the semi-extended position, and the extended position of the lower leg allows for easier fluoroscopic imaging. In this study, we aimed to compare the outcomes between SP and infrapatellar (IP) approaches of intramedullary nailing in patients with extra-articular tibial fractures. Method A randomized control trial was conducted over a period of 1.5 years at our tertiary care hospital after obtaining approval from its institutional ethics committee. A total of 60 patients with extra-articular tibial fractures were included in the study, with 30 patients each in the SP nailing group and the IP nailing group, based on randomized sampling and with the help of radiological exposure in SP and IP nailing as per a previous study. The groups were then compared in terms of KUJALA patellofemoral knee score, operative time, radiation exposure, and time of union. Results When comparing both groups, those treated with the SP approach had better outcomes, including reduced radiation exposure, less pain, decreased operative time, better KUJALA patellofemoral knee score, and faster union. Conclusion Based on our findings of the comparison between SP and IP nailing approaches of extra-articular tibial fractures, the former leads to better and safer outcomes than the latter.
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Affiliation(s)
- Nilesh Joshi
- Orthopaedics and Traumatology, N. K. P. Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital, Nagpur, IND
| | - Shantanu Deshkmukh
- Orthopaedic Surgery, N. K. P. Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital, Nagpur, IND
| | - Yash Shewale
- Orthopaedics, N. K. P. Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital, Nagpur, IND
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Yang CY, Tay ST, Kuo LT. Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis. J Orthop Traumatol 2023; 24:14. [PMID: 37041367 PMCID: PMC10090252 DOI: 10.1186/s10195-023-00694-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/19/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing. METHOD This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data. RESULTS Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00). CONCLUSIONS With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures. LEVEL OF EVIDENCE Level III, systematic review of non-randomized studies.
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Affiliation(s)
- Chen-Yuan Yang
- Department of Orthopedics, Kuang Tien General Hospital, Taichung, 433, Taiwan
- Department of Nursing, Hungkuang University, Taichung, 433, Taiwan
| | - Soon-Tzeh Tay
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Liang-Tseng Kuo
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6 Western Sec., Chia-Pu Road, Putzi City, Chiayi, 613, Taiwan.
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Jayaraju U, Rammohan R, Awad F, Kaur K, Brock J, Singhal A, Clewer G. Tibial Intramedullary Nailing by Suprapatellar Approach: Is It Quicker and Safer? Cureus 2022; 14:e29915. [PMID: 36348901 PMCID: PMC9633433 DOI: 10.7759/cureus.29915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
Abstract
Background With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods This is a retrospective cohort analysis of 34 SP tibial nails over three years vs 24 IP tibial nails over a similar time frame. We compared total radiation dose (TRD), patient positioning time (PPT), fracture healing and follow up time. Knee pain in the SP group was evaluated utilising the Hospital for Special Surgery (HSS) Knee Injury and Osteoarthritis Outcome Score (KOOS). Results Fifty-eight patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78 cGy (range: 11.60-156.01 cGy) vs 121.09 cGy (range: 58.01-18.03 cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow up was 5.5 months vs 11 months in the IP and SP groups, respectively. Mean KOOS was 7 (range: 0-22) at six months for the SP group. Conclusion The semi-extended position (SP group) leads to reduced TRD because of ease of imaging. Patients showed improved outcomes with shorter follow up and fracture union in all patients (SP group). The KOOS revealed that SP nail patients had minimal pain and good knee function. This study establishes a management and patient-reported outcome measures (PROMs) baseline for ongoing evaluation of SP nails.
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Proximal to midshaft closed tibial fracture - Infra or supra-patellar nailing? Injury 2022; 53:3067-3069. [PMID: 35945089 DOI: 10.1016/j.injury.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Ylitalo AAJ, Dahl KA, Reito A, Ekman E. Changes in operative treatment of tibia fractures in Finland between 2000 and 2018: A nationwide study. Scand J Surg 2022; 111:65-71. [PMID: 36000729 DOI: 10.1177/14574969221111612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Incidences of different tibia fractures are not well reported. Possible changes in the operative treatment methods have also not been studied. The aim of this nationwide registry study is to determine the incidence of operatively treated tibia fractures and investigate the possible changes in treatment methods in Finland between 2000 and 2018. METHODS All patients aged 16 years or older with operatively treated tibia fractures in Finland from 2000 to 2018 were included. The incidence of operatively treated proximal, diaphyseal, and distal tibia fractures per 100,000 person years by age, sex, mechanism of injury, and study year was calculated. Data were extracted from the Finnish National Hospital Discharge Register. RESULTS A total of 5996 proximal, 6874 diaphyseal, and 5658 distal tibia fractures were reported during the 18-year study period, resulting in incidences of 7.2/100,000, 8.1/100,000, and 6.9/100,000 person years for operatively treated proximal, diaphyseal, and distal tibia fractures, respectively. Over the study period, a clear change in fixation method in distal tibia fractures was found as plating became popular in the beginning of the 21st century. During the last 5 years of the study period, nailing and plating were equally used. CONCLUSIONS Operatively treated proximal tibia fractures are most common among older females while diaphyseal fractures are most frequent in young male patients. Distal tibia fractures occur most often among middle-aged people.
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Affiliation(s)
- Antti A J Ylitalo
- Department of Orthopedic Surgery Tampere University Hospital University of Tampere PL 2000 Elämänaukio 2 33521 Tampere Finland
| | - Kalle A Dahl
- Department of Orthopaedic Surgery, Turku University Hospital, Turku, Finland
| | - Aleksi Reito
- Department of Orthopaedic Surgery, Tampere University Hospital, Tampere, Finland
| | - Elina Ekman
- Department of Orthopaedic Surgery, Turku University Hospital, Turku, Finland
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Novoa-Sierra B, Estrems-Diaz V, Bertó-Martí X, Fuentes-Real S, Hernandez-Ferrando L. [Translated article] Metaphysary fractures of the distal tibia: Comparative analysis of the results obtained by means of a blocked plate and intramedular nail. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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17
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Fracturas metafisarias de tibia distal: analisis comparativo de los resultados obtenidos mediante placa bloqueada y clavo intramedular. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:298-305. [DOI: 10.1016/j.recot.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/25/2021] [Accepted: 03/05/2022] [Indexed: 11/23/2022] Open
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Sepehri A, You D, Lobo AA, Schneider P, Lefaivre KA, Guy P. Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis. J Orthop Trauma 2022; 36:e208-e214. [PMID: 34799545 DOI: 10.1097/bot.0000000000002303] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Aresh Sepehri
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada; and
| | - Daniel You
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Akshay A Lobo
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada; and
| | - Prism Schneider
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Kelly A Lefaivre
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada; and
| | - Pierre Guy
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada; and
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. [Translated article] Suprapatellar tibial nailing, why have we changed? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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20
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. Enclavado de tibia suprapatelar, ¿por qué hemos cambiado? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:159-169. [DOI: 10.1016/j.recot.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 08/18/2021] [Accepted: 09/07/2021] [Indexed: 10/19/2022] Open
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Llano L, Soruco ML, Taype Zamboni D, Sancineto C, Barla J, Carabelli G. Comparison between functionality and quality of reduction between suprapatellar vs infrapatellar approaches in the treatment of diaphyseal and distal tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:889-892. [PMID: 35175422 DOI: 10.1007/s00590-022-03230-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/04/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Intramedullary nailing is the most frequent procedure used for the treatment of tibial fractures that do not involve the articular surfaces. The goal of this study is to analyse the clinical outcomes, time of surgery and use of fluoroscopy in patients with midshaft and distal tibial fractures treated with suprapatellar and infrapatellar nailing and compare the results between these different groups. METHODS A retrospective study was conducted, and patients were selected between the period of March 2018 and October 2019. The following variables were studied: age, gender, AO classification, time of surgery (minutes), time of fluoroscopy (seconds), quality of reduction in postoperative controls and 1 year follow-up (using the angles MPTA, LDTA, PPTA, ADTA). Functional outcomes were studied at 1 month and 1 year follow-up. The visual analogue scale was used to study and compare the postoperative pain of the patients. The Lysholm Knee Score was used to evaluate the functional outcomes of the patients. RESULTS A total of 80 patients meeting the inclusion criteria were included in this study. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 patients. The time of surgery (p=0.008) and the mean time of use of fluoroscopy (p <0.001) difference were significant in favour of the suprapatellar approach. In the quality of reduction analysis, we have statistically significant results in the LDTA and ADTA angles. Also, in the evaluation of postoperative pain, significant difference was found in favour of the suprapatellar approach. CONCLUSION In conclusion, our study compared the suprapatellar approach and the infrapatellar approach for the treatment of midshaft and distal tibia fractures with intramedullary nailing. The results showed lesser time of surgery and use of fluoroscopy, lower knee pain, and lower rate of malalignment with the suprapatellar approach than with the infrapatellar approach.
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Affiliation(s)
- Lionel Llano
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina.
| | - Maria Liliana Soruco
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina
| | - Danilo Taype Zamboni
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina
| | - Carlos Sancineto
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina
| | - Jorge Barla
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina
| | - Guido Carabelli
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Tte. Gral. Juan D. Perón, 4190 C1199ABB, Buenos Aires, Argentina
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22
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Suprapatellar versus infrapatellar approach for intramedullary nail fixation of tibial shaft fractures: a review of the literature. OTA Int 2022; 5:e196. [PMID: 35187413 PMCID: PMC8843371 DOI: 10.1097/oi9.0000000000000196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 02/07/2023]
Abstract
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.
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23
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Patel AH, Wilder JH, Lee OC, Ross AJ, Vemulapalli KC, Gladden PB, Martin MP, Sherman WF. A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular. Orthop Rev (Pavia) 2022; 14:31909. [PMID: 35106131 PMCID: PMC8801390 DOI: 10.52965/001c.31909] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
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.
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Affiliation(s)
- Akshar H Patel
- Orthopaedic Surgery, Tulane University School of Medicine
| | - J Heath Wilder
- Orthopaedic Surgery, Tulane University School of Medicine
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Tulane University School of Medicine; Department of Orthopaedic Surgery, Louisiana State University School of Medicine and Southeast Louisiana Veterans Health Care System
| | - Austin J Ross
- Orthopaedic Surgery, Tulane University School of Medicine
| | | | - Paul B Gladden
- Orthopaedic Surgery, Tulane University School of Medicine
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24
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Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Umur L, Sari E, Orhan S, Sürücü S, Yildirim C. Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage. Int J Clin Pract 2022; 2022:8220030. [PMID: 35685529 PMCID: PMC9159120 DOI: 10.1155/2022/8220030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/03/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Levent Umur
- Acıbadem Kadıköy Hospital, Orthopedics and Traumatology Department, Tekin Sokak No. 8 Acıbadem Kadıköy, Istanbul, Turkey
| | - Enes Sari
- Orthopaedics and Traumatology Department, Near East University Hospital, Mersin-10, Turkey
| | - Serdar Orhan
- Orthopaedics and Traumatology Department, Sultan Abdulhamid Han Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - Serkan Sürücü
- University of Missouri, Kansas, Department of Orthopedic Surgery, USA
| | - Cengiz Yildirim
- Orthopaedics and Traumatology Department, Sultan Abdulhamid Han Training and Research Hospital, Uskudar, Istanbul, Turkey
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Zhu Z, Wang Z, Zhou P, Wang X, Guan J. Comparison of clinical efficacy of suprapatellar and infrapatellar intramedullary nailing in treating tibial shaft fractures. Pak J Med Sci 2021; 37:1753-1757. [PMID: 34912390 PMCID: PMC8613067 DOI: 10.12669/pjms.37.7.4766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 05/26/2021] [Accepted: 07/08/2021] [Indexed: 11/25/2022] Open
Abstract
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
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Affiliation(s)
- Zhonglian Zhu
- Zhonglian Zhu, Anhui Key Laboratory of Tissue Transformation, Bengbu Medical College, Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Rd, Bengbu 233000, Anhui Province, P.R. China
| | - Zhaodong Wang
- Zhaodong Wang, Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Rd, Bengbu 233000, Anhui Province, P.R. China
| | - Pinghui Zhou
- Pinghui Zhou, Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Rd, Bengbu 233000, Anhui Province, P.R. China
| | - Xuyi Wang
- Xuyi Wang, Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Rd, Bengbu 233000, Anhui Province, P.R. China
| | - Jianzhong Guan
- Jianzhong Guan, Anhui Key Laboratory of Tissue Transformation, Bengbu Medical College, Department of Orthopedics, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Rd, Bengbu 233000, Anhui Province, P.R. China
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Infrapatellar Saphenous Nerve Is at Risk During Tibial Nailing: An Anatomic Study. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202110000-00003. [PMID: 34605774 PMCID: PMC8492372 DOI: 10.5435/jaaosglobal-d-21-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/29/2021] [Indexed: 11/18/2022]
Abstract
To determine the location and stage of the tibial nailing procedure where infrapatellar saphenous nerve (IPSN) injury may occur.
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Bleeker NJ, Reininga IHF, van de Wall BJM, Hendrickx LAM, Beeres FJP, Duis KT, Doornberg JN, Jaarsma RL, Kerkhoffs GMMJ, IJpma FFA. Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients. J Orthop Trauma 2021; 35:391-400. [PMID: 34267147 PMCID: PMC8253504 DOI: 10.1097/bot.0000000000002043] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Nils Jan Bleeker
- Department of Orthopaedic Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Inge H. F. Reininga
- Department of Orthopaedic Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bryan J. M. van de Wall
- Department of Orthopaedic Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Laurent A. M. Hendrickx
- Department of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia; and
- Department of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam Movement Sciences (AMS), University of Amsterdam, Amsterdam, the Netherlands
| | - Frank J. P. Beeres
- Department of Orthopaedic Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Kaj ten Duis
- Department of Orthopaedic Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia; and
| | - Ruurd L. Jaarsma
- Department of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia; and
| | - Gino M. M. J. Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam Movement Sciences (AMS), University of Amsterdam, Amsterdam, the Netherlands
| | - Frank F. A. IJpma
- Department of Orthopaedic Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Abstract
INTRODUCTION Tibial shaft fractures are common injuries in the adolescent age group. Potential complications from the injury or treatment include infection, implant migration, neurovascular injury, compartment syndrome, malunion, or nonunion. METHODS Published literature was reviewed to identify studies which describe the management options, complications, and outcome of tibial shaft fractures in adolescents. RESULTS Acceptable alignment parameters for tibial shaft fractures have been defined. Operative indications include open fractures and other severe soft tissue injuries, vascular injury, compartment syndrome, ipsilateral femoral fractures, and polytrauma. Relative indications for operative treatment are patient/family preference or morbid obesity. Closed reduction and cast immobilization necessitates radiographic observation for loss of reduction over the first 3 weeks. Cast change/wedging or conversion to operative management may be required in 25% to 40%. Flexible nailing provides relative fracture stability while avoiding the proximal tibial physis, but the fracture will still benefit from postoperative immobilization. Rigid nailing provides greater fracture stability and allows early weight bearing but violates the proximal tibial physis. Plate and screw osteosynthesis provide stable anatomic reduction, but there are concerns with delayed union and wound complications related to the dissection. External fixation is an excellent strategy for tibia fractures associated with complex wounds but also requires observation for loss of reduction. DISCUSSION AND CONCLUSIONS The majority of adolescent tibia shaft fractures can be successfully managed with closed reduction and cast immobilization. Unstable fractures that have failed cast treatment should be treated operatively. Flexible intramedullary nailing, rigid intramedullary nailing, plate and screw osteosynthesis, and external fixation are acceptable treatment options that may be considered for an individual patient depending upon the clinical scenario.
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Kang H, Rho JY, Song JK, Choi J, Kwon YS, Choi S. Comparison between intramedullary nailing and minimally invasive plate osteosynthesis for tibial shaft fractures. Injury 2021; 52:1011-1016. [PMID: 33563414 DOI: 10.1016/j.injury.2021.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing (IMN) is currently considered the gold standard in the surgical treatment of tibial shaft fractures in adult patients. In this case-control comparative study, we aimed to compare the efficacy of minimally invasive plate osteosynthesis (MIPO) and IMN in treating tibial shaft fractures. MATERIALS AND METHODS The clinical and radiological outcomes, such as a modified trauma scale, operation time, fracture healing, rate of re-operation, and complications such as malunion, nonunion, shortening, and infection were assessed between IMN and MIPO for the treatment of tibial shaft fractures. RESULTS Seventy-three skeletally mature patients who underwent IMN (group I) or MIPO (group M) for a closed extra-articular tibial shaft fracture (AO/OTA type 42) from June 2010 to May 2016 were retrospectively reviewed. The mean age was 51.16 (18~79) years, and the mean follow-up period was 22 (12~50) months. Bony union was achieved in all cases but one for each group - group I (35 cases) and group M (36 cases) (p > 0.05). Mean callus formation was observed in 12 (8 - 16) weeks in both groups (p > 0.05). There was no significant difference in operative time, hospital stay, bone healing, and the rate of complications among the two groups (p > 0.05). There was also no postoperative difference in functional evaluation between the two methods (p > 0.05). CONCLUSIONS No discrepancy was found in radiological and clinical outcomes between IMN and MIPO for tibial shaft fractures. It can be concluded that both IMN and MIPO are equally effective treatment modalities for tibial shaft fractures.
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Affiliation(s)
- Hyunseong Kang
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Joseph Y Rho
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Jung-Kook Song
- Department of Preventive Medicine¸ Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Jaewon Choi
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Yong Suk Kwon
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Sungwook Choi
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Ara-1-dong, Jeju city, Jeju, Republic of Korea.
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Bleeker NJ, van de Wall BJM, IJpma FFA, Doornberg JN, Kerkhoffs GMMJ, Jaarsma RL, Knobe M, Link BC, Babst R, Beeres FJP. Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients. Injury 2021; 52:345-357. [PMID: 33268081 DOI: 10.1016/j.injury.2020.10.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- N J Bleeker
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland.
| | - B J M van de Wall
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F F A IJpma
- Dept. of Trauma Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - J N Doornberg
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - G M M J Kerkhoffs
- Dept. of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R L Jaarsma
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - M Knobe
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - B C Link
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - R Babst
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F J P Beeres
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
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Packer TW, Naqvi AZ, Edwards TC. Intramedullary tibial nailing using infrapatellar and suprapatellar approaches: A systematic review and meta-analysis. Injury 2021; 52:307-315. [PMID: 32998824 DOI: 10.1016/j.injury.2020.09.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Timothy W Packer
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK..
| | - Ali Z Naqvi
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Thomas C Edwards
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.; MSk Lab, Imperial College London, London, UK
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Ponugoti N, Rudran B, Selim A, Nahas S, Magill H. Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:94. [PMID: 33509237 PMCID: PMC7844899 DOI: 10.1186/s13018-021-02249-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/19/2021] [Indexed: 01/14/2023] Open
Abstract
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.
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Fontalis A, Weil S, Williamson M, Houston J, Ads T, Trompeter A. A comparison of anterior knee pain, kneeling pain and functional outcomes in suprapatellar versus infrapatellar tibial nailing. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1143-1150. [PMID: 33417043 DOI: 10.1007/s00590-020-02851-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/15/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Simon Weil
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Michael Williamson
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - James Houston
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Tamer Ads
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK.
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Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial. J Orthop Trauma 2020; 34:612-619. [PMID: 33065663 DOI: 10.1097/bot.0000000000001802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare a modern ring fixator [Taylor Spatial Frame (TSF)] and reamed intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures. DESIGN Randomized controlled trial. SETTING Two university hospitals. PATIENTS Patients between 18 and 70 years of age surgically treated for an acute tibial shaft fracture. INTERVENTION TSF (n = 31) versus a reamed intramedullary nail (n = 32). The patients were followed up for 2 years. MAIN OUTCOME MEASUREMENTS The physical component summary of Short Form 36 (SF-36) at 2 years was the primary outcome measure. Secondary outcomes included the other components of the SF-36, pain assessed by a visual analogue scale (VAS), complications, and resource consumption. RESULTS The mean age was 43 years (SD 14.0), and 42 (67%) were men. The physical component summary at 2 years was 52.4 (SD 6.3) in the TSF group and 53.3 (SD 8.0) in the IMN group (P = 0.35). There were modest differences in the other SF-36 scores during the follow-up period. Up to and including 12 months, the TSF group had less knee pain [at 12 months: VAS 0.5 (SD 1.2) vs. VAS 2.4 (SD 2.2; P < 0.001)], but this was not statistically significant at 24 months [VAS 0.7 (SD 1.4) vs. VAS 1.5 (SD 2.0; P = 0.11)]. Superficial skin infections were more frequent in the TSF group [22 (71%) vs. 4 (13%); P < 0.001]. The number of other complications was similar between the groups. CONCLUSIONS Both TSF and IMN provided good clinical results. TSF had more pin-track infections but less knee pain the first year. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Lu Y, Wang G, Hu B, Ren C, Sun L, Wang Z, He C, Xue H, Li Z, Zhang K, Ma T, Wang Q. Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures. J Orthop Surg Res 2020; 15:422. [PMID: 32943096 PMCID: PMC7500032 DOI: 10.1186/s13018-020-01960-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background This study aimed to analyze and compare the clinical and functional outcomes of distal tibia fractures treated with intramedullary nailing (IMN) using the suprapatellar (SP) and infrapatellar (IP) surgical approaches. Methods A retrospective analysis was performed in 63 patients with distal fractures that were treated with IMN between August 2014 and August 2018. A total of 27 and 36 patients underwent IMN using the SP and IP techniques, respectively. The surgical time, blood loss, closed reduction rate, rate of adjuvant reduction technique, fracture healing time, and complications were reviewed in this study. Anterior knee pain was assessed using the visual analog scale. The Lysholm Knee Scoring Scale and American Orthopaedic Foot and Ankle Society (AOFAS) scale were used as clinical measurements. Results A total of 63 patients, with a minimum follow-up of 12 months, were evaluated. The average surgical time, blood loss, rate of adjuvant reduction technique, closed reduction rate, fracture healing time, and Lysholm Knee Scoring Scale score were insignificantly different (P > 0.05) between the two groups. However, the SP approach was superior to the IP approach in terms of pain score, AOFAS score, and fracture deformity rate (P < 0.05). Conclusions In the treatment of distal tibia fractures, the SP IMN technique is associated with a significantly higher functional outcome, lower knee pain, and lower rate of fracture deformity than the IP IMN technique.
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Affiliation(s)
- Yao Lu
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China.,Bioinspired Engineering and Biomechanics Center (BEBC), School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Gen Wang
- Orthopaedics Institute of Chinese PLA, 80th Hospital, 3770 Beigongxijie, Weifang, Shandong Province, China
| | - Bin Hu
- Department of Hematology, Xi'an Gao Xin Hospital, Xi'an, 710054, Shaan'xi Province, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Liang Sun
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Zhimeng Wang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Changjun He
- Yan'an University, Yan'an, 710000, Shaanxi, China
| | - Hanzhong Xue
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Zhong Li
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China
| | - Teng Ma
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China. .,Bioinspired Engineering and Biomechanics Center (BEBC), School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China.
| | - Qian Wang
- Department of Orthopaedic Surgery, HongHui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Xi'an, 710054, Shaan'xi Province, China.
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Singh AK, Sait S, Khan Y, Al-Obaidi B, Bhattacharya R. Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre. Injury 2020; 51:1642-1646. [PMID: 32434715 DOI: 10.1016/j.injury.2020.04.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/01/2020] [Accepted: 04/27/2020] [Indexed: 02/02/2023]
Abstract
Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach. Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 - 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores. Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1). Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.
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Affiliation(s)
- Ashok K Singh
- Department of Trauma & Orthopaedics, North West London Major Trauma Centre, Imperial College Healthcare NHS Trust, St Marys Hospital, Paddington, W2 1NY.
| | - Saif Sait
- Department of Trauma & Orthopaedics, North West London Major Trauma Centre, Imperial College Healthcare NHS Trust, St Marys Hospital, Paddington, W2 1NY.
| | - Yasmeen Khan
- Department of Trauma & Orthopaedics, Chelsea and Westminster Hospital, London SW10 9NH.
| | - Bilal Al-Obaidi
- Department of Trauma & Orthopaedics, North West London Major Trauma Centre, Imperial College Healthcare NHS Trust, St Marys Hospital, Paddington, W2 1NY.
| | - Rajarshi Bhattacharya
- Department of Trauma & Orthopaedics, North West London Major Trauma Centre, Imperial College Healthcare NHS Trust, St Marys Hospital, Paddington, W2 1NY.
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38
|
|