Incidence and aetiology of anterior knee pain after intramedullary nailing of the femur and tibia

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Lateral Para-Patellar Approach for Intramedullary Tibia Nailing in Distal Tibia Extra-articular Fractures: A Prospective Cohort Study

BACKGROUND AND OBJECTIVES

 The treatment of extra-articular distal tibia fractures is still a subject of debate and frequently necessitates surgical treatment, and intramedullary nailing (IMN) offers a minimally invasive approach with excellent results. Important factors in these procedures are positioning, operative duration, and radiation exposure. This study details the semi-extended lateral para-patellar approach for IMN of distal tibia extra-articular fractures and documents our findings regarding operative time, intra-operative radiation exposure, residual anterior knee pain, knee functional and radiological outcomes at six months follow-up.

METHODS

We reviewed the cases of 60 patients who underwent IMN for distal tibia extra-articular fractures from May 2022 to March 2024, employing an extra-articular lateral para-patellar approach in the semi-extended position. Patients were evaluated clinically and radio-graphically for a minimum follow-up period of six months. Data collected included duration of surgery, intraoperative radiation exposure, and knee functional score for all patients. Assessment of fracture healing, residual deformities, residual anterior knee pain, and range of motion of the treated knee compared to the contralateral knee was done at a six-month follow-up.

RESULTS

The average surgery duration was 54 ± 5 minutes, with intraoperative imaging averaging 48 exposures. The average time to union was 16 ± 3 weeks. Six months post-surgery, the mean Knee Society Score was 86.4 ± 3.5 (out of 100). At the six months follow-up, all patients exhibited clinical and radiographic healing, with only two cases showing mal-alignment (angular deformity <10 degrees). All patients regained a comparable range of motion in their knees.

CONCLUSIONS

The semi-extended lateral para-patellar approach for nailing of distal tibia extra-articular fractures enhances reduction, simplifies nail insertion, reduces both fluoroscopy and operative time, minimizes anterior knee pain and improves knee functional outcomes at six months follow-up.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Gait and strength assessment following surgical repair by intramedullary nailing of isolated tibial shaft fracture

The objective of the study was to evaluate the long-term strength and gait outcomes after intramedullary nailing of isolated tibial diaphyseal fractures. This retrospective cohort study was conducted at an academic Level I trauma center. Fifteen participants with isolated tibial diaphyseal fractures (OTA/AO 42) at least 2 years postoperative from intramedullary nailing (IMN) provided informed consent. The average age was 40 ± 14 (range, 24-69); there were nine men and six women. Knee flexion-extension strength data were collected. Temporal-spatial, kinematic, and kinetic gait parameters were measured and compared to historic control data. Participants completed the SF-36 and shortened musculoskeletal function assessment questionnaires. The mean length of follow-up between surgery and gait analysis was 6 ± 2 years. The fractured limb demonstrated deficits in quadriceps strength between 9.8% and 23.4% compared to the unaffected limb. Temporal-spatial parameters revealed slower walking speed, shorter stride length, decreased cadence, and shorter single-limb support time in the fractured limb. Altered kinematic and kinetic findings included a knee extension shift during stance, with an increased knee flexor moment demand and decreased total knee power during loading and midstance. These findings represent deficits in concentric and eccentric knee extensor activity. Additionally, the fractured limb demonstrated decreased ankle dorsiflexion during stance and diminished ankle push-off power. Long-term outcomes after IMN of tibial diaphyseal fractures demonstrate decreased quadriceps strength and altered gait parameters that may have implications to the high incidence of knee and ankle pain in the fractured limb.

Tibial fractures treated with mono-lateral fixation: Principles of design and application

This paper presents the outcome of a data review of patients treated with the IOS external fixation system at the Royal Stoke University Hospital: a fixation designed to meet four requirements for external fixation proposed in this paper. Demographic data and outcome were collected and assessed. From 69 initial patients, 64 patients (55 males and 9 females) had an average age of 35.9 years. The mean time to union was 127 days. There were no incidences of malunion, or refracture post fixation removal attributable to the treatment method. In addition, in this cohort, there was no incidence of pin tract infection resulting in osteomyelitis. Of all the factors assessed the only factor to have any significant effect on healing was smoking: an average delay of 31 days. An examination of RUST (radiographic union score tibia) and modified RUST scores illustrated a potential false negative of up to 80%. Hence, this study cannot support the use of either scoring system to diagnose fracture healing. IOS external fixation was shown to be an effective method for the treatment of unstable tibial fractures. The reduction at fixation removal was shown to be very good. There was no incidence of osteomyelitis. It is, therefore, suggested that appropriately used external fixation is a viable alternative to intramedullary nailing if designed and surgically applied using four design principles outlined in this paper. Furthermore, it is proposed that external fixation be designed and applied to meet these four principles.

In-person cognitive behavioural therapy vs. usual care after surgical management of extremity fractures: an unsuccessful feasibility trial

BACKGROUND

Extremity fractures are common, and most are managed operatively; however, despite successful reduction, up to half of patients report persistent post-surgical pain. Furthermore, psychological factors such as stress, distress, anxiety, depression, catastrophizing, and fear-avoidance behaviors have been associated with the development of chronic pain. The purpose of this pilot study was to examine the feasibility of a randomized controlled trial to determine the effect of in-person cognitive behavioral therapy (CBT) vs. usual care on persistent post-surgical pain among patients with a surgically managed extremity fracture.

METHODS

Eligible patients were randomized to either in-person CBT or usual care. We used four criteria to judge the composite measure of feasibility: 1) successful implementation of CBT at each clinical site, 2) 40 patients recruited within 6 months, 3) treatment compliance in a minimum 36 of 40 participants (90%), and 4) 32 of 40 participants (80%) achieving follow-up at one year. The primary clinical outcome was persistent post-surgical pain at one year after surgery.

RESULTS

Only two of the four participating sites were able to implement the CBT regimen due to difficulties with identifying certified therapists who had the capacity to accommodate additional patients into their schedule within the required timeframe (i.e., 8 weeks of their fracture). Given the challenges associated with CBT implementation, only one site was able to actively recruit patients. This site screened 86 patients and enrolled 3 patients (3.5%) over a period of three months. Participants were unable to comply with the in-person CBT, with no participants attending an in-person CBT session. Follow-up at one year could not be assessed as the pilot study was stopped early, three months into the study, due to failure to achieve the other three feasibility criteria.

CONCLUSION

Our pilot trial failed to demonstrate the feasibility of a trial of in-person CBT versus usual care to prevent persistent pain after surgical repair of traumatic long-bone fractures and re-enforces the importance of establishing feasibility before embarking on definitive trials. Protocol modifications to address the identified barriers include the delivery of our intervention as a therapist-guided, remote CBT program.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier NCT03196258); Registered June 22, 2017, https://clinicaltrials.gov/ct2/show/NCT03196258.

Effect of intramedullary nail fixation and internal plate fixation in distal tibia fracture surgery on post-operative wound infection in patients: A meta-analysis

Distal tibial fracture is the most commonly seen type of fracture of the lower extremities. Both intramedullary nail fixation (INF) and plate fixation (PF) have been used to treat distal tibial fractures, but the best way to treat them is still in dispute. The purpose of this meta-analysis is to compare INF versus PF fixation with respect to the incidence of injury. For studies that have been published between inception and June 2023, a systematic review has been carried out on PubMed, Embase, Cochrane Library and Web of Scientific databases. All of the trials that looked at INF and PF-related complications were enrolled. Data from the 13 primary results were analysed with RevMan 5.3. The meta-analyses comprised 13 randomized controlled trials (RCTs). INF indicates that there is a tendency for patients with distal tibia fractures to reduce the risk of operative site infection (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.40, 3.13; p = 0.0003) after surgery compared with PF. INF resulted in a reduction in total wound complications (OR, 14.20; 95% CI, 1.81, 111.57; p = 0.01) but shortened operation time (mean difference, 13.03; 95% CI, 2.08, 23.99; p = 0.02). In view of these findings, INF seems to be a preferred method of surgery for the treatment of distal tibial fractures with respect to the reduction of post-operative wound complications.

Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery

BACKGROUND

Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use.

METHODS

This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured.

RESULTS

RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05).

CONCLUSIONS

RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Reduction of Operative Time, Intraoperative Radiographs, and Anterior Knee Pain With the Lateral Parapatellar Approach for Tibial Shaft Fracture Nailing: A Case Series

Background Tibia fracture is a common indication for operative intervention in orthopedics. Usage of Intramedullary nailing provides a minimally invasive technique with good results. Positioning, operative time, and radiation exposure are major points in such cases. This study described the semi-extended lateral parapatellar intramedullary technique as a technique that helps achieve and maintain reduction, simplifies nail insertion, and decreases fluoroscopy and operative time. Methodology This prospective case series study included nine patients with tibial shaft fractures operated at Royal Rehabilitation Center from April to October 2023 by intramedullary nailing and extra-articular lateral parapatellar insertion technique using the semi-extended knee position. Duration of surgery, intraoperative radiation exposure, and anterior knee pain score were assessed for all patients. Results The average duration of surgery was 63.78 ± 5.3 minutes, and the average intraoperative imaging was 94 (85-103). The average union time was 18 ±2 weeks. The mean Kujala score was 90.9% ± 2.3% six months after the surgery. All patients regained a comparable range of motion in their knees and ankles. One patient reported minimal pain at the pin site but did not require any analgesia. Conclusion The lateral parapatellar approach for tibial shaft fracture nailing has the advantage of reducing operative time, the number of intraoperative radiographs, and lower postoperative anterior knee pain. Additionally, this approach did not cause patellar instability.

Semi-extended extra-synovial (SEES) tibial intramedullary nailing technique: Up to 10 year retrospective analysis of outcomes and anterior knee pain rates

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.

Surgical Treatment of Saphenous Nerve Injury Assisted by Plasma Rich in Growth Factors (PRGF): Lessons from a Case Report

The infrapatellar branch of the saphenous nerve (SN) is a widely described anatomic and functional structure; however, its relevance in daily clinical practice is underestimated. All surgical procedures performed on the anteromedial aspect of the knee are associated with a risk of iatrogenic injury to this nerve, including knee arthroscopy, knee arthroplasty, tibial nailing, etc. We present the case of a saphenous nerve neuroma after treatment with radiofrequency thermal ablation due to a knee pain problem. After conducting an anaesthetic suppression test, we decided to perform a denervation of the medial saphenous nerve in Hunter's canal. We performed surgery on the anteromedial aspect of the knee. The distal end of the medial SN was coagulated with a bipolar scalpel. The proximal end of the nerve was released proximally, and a termino-lateral suture was made at the free end of the nerve after creating an epineural window to inhibit its growth. A double crush was produced proximally to the suture site to create a grade II-III axonal injury. Autologous plasma rich in growth factors (PRGF) was used to reduce potential post-surgical adhesions and to stimulate regeneration of the surgical lesions. One year after surgery, the patient was living a completely normal life.

Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures

INTRODUCTION

Distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the preoperative consent process.

HYPOTHESIS

There is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures.

MATERIAL AND METHODS

Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44years. Mean overall follow-up was 13.3months (range 8-25, SD 3.6). All fractures had completely healed without postoperative complication.

RESULTS

The IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs. 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs. 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs. 6.9 respectively, p=0.040; mean FJS 38.3 vs. 75.9 respectively, p=0.005).

DISCUSSION

The use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes.

LEVEL OF EVIDENCE

IV; retrospective cohort study with quantitative outcome measurement.

Knee Pain After Retrograde Intramedullary Nailing with Surgical Implant Generation Network of Femur Shaft Fractures at Public Hospitals in Bahir Dar City, Ethiopia: Analysis of 6-Months Follow-Up Results

Background

The incidence of femur fractures in young and elderly people has increased, particularly in countries with limited resources like Ethiopia. Intra-medullary nailing (IM) has been an effective and cost-effective method of treating long bone shaft fractures, but it can lead to complications such as knee pain.

Purpose

This study aimed to evaluate knee pain and its associated factors following retrograde intramedullary nailing for femur fractures.

Patients and Methods

The study followed 110 patients diagnosed with femur fractures and treated with retrograde SIGN Standard Nail or Fin Nail from January 2020 to December 2022 at two hospitals in Ethiopia. The patients were followed up for at least 6 months, and data were collected from medical charts, patient interviews, and phone calls to patients who did not attend the follow-up appointment. Binary logistic regression analysis was used to identify factors associated with knee pain.

Results

The study showed that 40 patients reported knee pain at 6-months follow-up, making a prevalence of 36.4%. Factors significantly associated with knee pain were a time of injury to nailing (AOR=4.23, 95% CI: 1.28-13.92), use of a screw to the medial cortex (AOR=9.30, 95% CI: 2.90-12.74), and fracture site (AOR= 2.67, 95% CI: 14.01-7.03). Specifically, the longer the time from injury to nailing, the higher the risk of knee pain. The use of a longer screw to the medial cortex and a fracture site were also positively associated with knee pain.

Conclusion

This study concludes that although retrograde intramedullary nail fixation is an effective method for femur fractures, it often results in knee pain. Approximately 4 of 10 patients suffered from knee pain in this study. Avoiding delayed surgical management and minimizing the use of prominent metalwork may reduce knee pain.

Cognitive Behavioural Therapy to Optimize Post-Operative Fracture Recovery (COPE): protocol for a randomized controlled trial

IMPORTANCE

Chronic, non-cancer pain affects approximately 20-30% of the population in North America, Europe, and Australia, with surgery and trauma frequently cited as inciting events. Prospective studies of fracture patients have demonstrated an association between somatic pre-occupation, poor coping, and low recovery expectations following surgery with persistent pain, functional limitations, and lower rates of return to work. Psychological interventions, such as cognitive behavioural therapy (CBT), that are designed to modify unhelpful beliefs and behaviours have the potential to reduce persistent post-surgical pain and its associated effects among trauma patients.

OBJECTIVE

To determine whether online CBT, versus usual care, reduces the prevalence of moderate to severe persistent post-surgical pain among participants with an open or closed fracture of the appendicular skeleton.

DESIGN, SETTING, AND PARTICIPANTS

The Cognitive Behavioural Therapy to Optimize Post-Operative Fracture Recovery (COPE) protocol will be followed to conduct a multi-centre randomized controlled trial. Participants undergoing surgical repair of a long bone fracture will be randomized to receive either (1) online CBT modules with asynchronous therapist feedback or (2) usual care. The primary outcome will be the prevalence of moderate to severe persistent post-surgical pain over 12 months post-fracture. Secondary outcomes include the Short Form-36 Physical and Mental Component Summary scores, return to function, pain severity and pain interference over 12 months post-fracture, and the proportion of patients prescribed opioid class medications (and average dose) at 6 and 12 months post-fracture. The COPE trial will enroll 1000 participants with open and closed fractures of the appendicular skeleton from approximately 10 hospitals in North America.

DISCUSSION

If CBT is effective in improving outcomes among patients with traumatic fractures, our findings will promote a new model of care that incorporates psychological barriers to recovery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04274530. Registered on 14 February 2020.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

Background

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

Methods

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

Discussion

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

Trial registration

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

Closure of the femoral medullary canal after retrograde nailing using an in-situ osteochondral autograft-Technical trick and a case series

Retrograde intramedullary nailing (RIMN) is the favored over antegrade intramedullary nailing in fractures of the distal femur. It provides a longer working length and allows for multiple distal screw insertion and therefore a more stable construct. Concerns remain regarding the violation of the knee cartilage and the effect this has on knee function. Many studies have shown high incidence of knee pain with reports varying from 20 to 86%. We describe a novel technical trick aiming at partially restoring the knee cartilage of the operated side and decreasing the hemorrhage stemming from the medullary canal. Our experience of the technique and the case series shows that closing the entrance point of the medullary canal after a RIMN procedure leads to better function and less knee pain in the postoperative period.

New method to remove tibial intramedullary nail through original suprapatellar incision: A case report

BACKGROUND

Since 2006, introducing a tibial intramedullary nail via the suprapatellar approach has been established; however, nail removal must be carried out using classic infrapatellar access, which can lead to complications. Here, we report a new method to remove the intramedullary nail through the original suprapatellar incision.

CASE SUMMARY

A 39-year-old man was hit by a vehicle in 2019. He was immobilized with a 10-mm × 330-mm tibial intramedullary nail via the suprapatellar approach due to left middle tibial fracture. Two years later, the patient requested for the implant to be removed. We used a new method to remove the tibial intramedullary nail through the original suprapatellar incision, and the operation went smoothly.

CONCLUSION

This case report indicates that suprapatellar access can be used to remove the intramedullary nail via the original incision without infrapatellar access, thus avoiding surgical complications.

Infrapatellar Saphenous Nerve Is at Risk During Tibial Nailing: An Anatomic Study

To determine the location and stage of the tibial nailing procedure where infrapatellar saphenous nerve (IPSN) injury may occur.

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

OBJECTIVES

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

DATA SOURCE

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Operative Fixation Versus Cast Immobilization: Tibial Shaft Fractures in Adolescents

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures

OBJECTIVE

To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach.

DESIGN

Retrospective chart review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018.

METHODS

A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders.

MAIN OUTCOME MEASUREMENTS

Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores.

RESULTS

There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores.

CONCLUSIONS

Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches.

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

CONCLUSION

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

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.

A comparative finite element simulation of locking compression plate materials for tibial fracture treatment

The locking compression plate (LCP) system has several advantages in fracture fixation combining angular stability with the use of locking screws with traditional fixation techniques. However, the system is complex and requiring careful attention to biomechanical principles and good surgical technique. Due to the set of complicate stresses and strains in the LCP system after implantation, the material, which is being used here, is deemed important. However, so far the materials have been limited to the stainless steel (SS) or titanium (Ti). This study was therefore aimed at investigate the biomechanical performance of the internal tibial locked plates at different material properties, including SS, Ti, carbon/polyether ether ketone (PEEK) composite, in treating medial tibial fracture using patient-specific finite element (FE) model of the human tibia. The carbon/PEEK composite materials were used at three different fiber plies configurations. Simulated loading was applied at 60:40 ratios on the medial:lateral aspect. The model was fixed distally in all degrees of freedom. The results revealed the highest stress (307.10 MPa) and the lowest strain (0.14%) at Ti LCP system. The carbon/PEEK LCP system at configuration I and III showed low stress (∼60 MPa) and high strain (0.70%), which are suitable points for designing of an internal LCP system. On the other hand, the highest value of stress in callus region was 4.78 MPa (Carbon PEEK/Configuration I) and the strain variations of callus region were between 1.46% and 3.82% among all materials. These results implied the advantage of carbon/PEEK composite materials in LCP system as they can tolerate higher strains at lower stresses.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Influence of Sagittal Proximal Tibial Anatomy in Tibial Intramedullary Nailing

OBJECTIVES

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

DESIGN

Retrospective cohort of prospectively collected data.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Effects of morphological changes in the patellar tendon on the development of anterior knee pain after intramedullary nailing for tibial shaft fractures: A retrospective comparative study

OBJECTIVE

This study aimed to investigate the effects of morphological changes of the patellar tendon (length, width, and thickness) on the development of anterior knee pain (AKP) after intramedullary nailing (IMN) of tibial shaft fractures.

METHODS

A total of 39 patients, treated by IMN using the transpatellar approach for tibial shaft fractures, were retrospectively reviewed and included in the study. The patients were then divided into 2 groups based on the presence of AKP: group A, patients who developed AKP (9 men, 9 women; mean age=35.39±9.32 years), and group B, patients without AKP (13 men, 8 women; mean age=41.38±14.78 years). To assess the morphological changes in the patellar tendon, magnetic resonance imaging was performed on the operated and unoperated, contralateral knees of the patients. The patellar tendon index (PTI) was calculated using the length, width, and thickness of the patellar tendon, and a set of variables was established to be a proportion of the measurements of the operated knees to those of the unoperated ones (operated/healthy PTI ratio). PTI ratios were compared between both the groups. Furthermore, the morphological features of the patellar tendon, including the length, width, and thickness, were examined within the groups as independent variables. To assess pain intensity in group A, a 10-cm visual analogue scale (VAS) was used. To evaluate functional status, the Lysholm knee scoring system was used.

RESULTS

The PTI ratio was significantly higher in group A (1.37±0.12) than in group B (1.03±0.08) (p<0.001). In group A, the mean VAS score was 5.35±1.11, and a moderate linear correlation was found between PTI ratios and VAS scores (r=0.494, p=0.044). The mean Lysholm score was significantly lower in group A (80.17±3.05) than in group B (89.76±3.05) (p<0.001). In group A, the width and thickness of the patellar tendon were found to be significantly different between the operated and unoperated knees (p=0.024 and p=0.002, respectively). In group B, there was no difference between the operated and unoperated knees in terms of the 3 measurements (length, width, and thickness) (p=0.762, p=0.753, and p=0.118, respectively).

CONCLUSION

Evidence from this study revealed that morphological changes occurring in the patellar tendon after IMN for tibial shaft fractures using a transpatellar approach may have a significant role in the development of AKP. The increase in the tendon width and thickness may be the cause of pain and insufficient knee function in such patients.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial

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.

Anatomical Study of the Infrapatellar Branch of the Saphenous Nerve in Humans

Objective  To perform an anatomical study of the location of the infrapatellar branch of the saphenous nerve in relation to the structures of the knee. Methods  An anatomical study was performed by dissection of 18 humans knees (9 right and 9 left knees). After exposure of the infrapatellar branch and its direct and indirect branches, they were then measured. We adopted a quadrant in the medial region of the knee delimited by two transversal planes as a parameter of the study. Results  In 17 of the 18 knees (94.4%) studied, a single infrapatellar branch was observed. The infrapatellar branch emerged as fibers of the womb of the sartorius muscle in 17 of the 18 knees (94.4%). In relation to the branch, we observed that in 100% of the knees the infrapatellar branch had at least one primary branch, resulting in a superior branch and an inferior branch. In 9 limbs (50% of the cases) this branch occurred outside the proposed quadrant, and, in the remaining limbs, it occurred within the quadrant. Conclusion  The infrapatellar saphenous nerve branch was found in all dissected knees, and, in 94.4% of the cases, it was of the penetrating type; in 100% of the cases, it originated two primary direct branches. The direct and indirect branches presented great variability regarding their path.

Epidemiologic trends for isolated tibia shaft fracture admissions in The Netherlands between 1991 and 2012

INTRODUCTION

Population-based knowledge on the occurrence of specific injuries is essential for the allocation of health care services, optimization of preventive measures, and research purposes. Therefore, the aim of this study was to examine long-term nation-based trends in the incidence rate, trauma mechanism, hospital length of stay (HLOS), treatment, and outcome of hospital-admitted patients with an isolated tibia shaft fracture between 1991 and 2012 in The Netherlands.

METHODS

All hospital-admitted patients in The Netherlands between 1991 and 2012 with an isolated tibia shaft fracture were included. Age and gender-standardized incidence rates were calculated for each year. Data were extracted from the National Medical Registration.

RESULTS

The incidence rate for men decreased to 13.8/100,000 person years (py). For women the incidence rate remained stable with 7.2/100,000 py. Incidence showed a peak for adolescent men (15-19 years), and increased in both genders from 65 years onwards. Since 1993 the mean HLOS for isolated tibia fractures reduced from 10.8 to 5.4 days. Mean HLOS increased with age. Mean years lived with disability (YLD) was 4.5 years, declined linearly with age, and showed no gender effect.

CONCLUSIONS

In 22 years, the incidence rate of hospital admitted patients with an isolated tibia shaft fracture in The Netherlands dropped with 12%, which was mainly attributable to a 15% decline among men. Incidence rate, trauma mechanism, and HLOS were age and gender related. HLOS also reduced over time. Operation rate and YLD were only age related.

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Therapeutic level III.

Comparison Between Nailing and Plating in the Treatment of Distal Tibial Fractures: A Meta-Analysis

BACKGROUND AND AIMS

To evaluate evidence on the superiority of plate fixation over intramedullary nail fixation in the treatment of distal tibial fractures regarding functional outcomes and complication rates.

MATERIAL AND METHODS

Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched in December 2019. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

RESULTS

The search resulted in 514 records, the final sample included 10 randomized controlled trials (782 patients). There were statistically significant differences in operating time (-11.2, 95% confidence interval: -16.3 to -6.1 min), time to partial weight bearing (-0.96, 95% confidence interval: -1.8 to -0.1 weeks), time to full weight bearing (-2.2, 95% confidence interval: -4.32 to -0.01 weeks), the rates of deep infections (risk ratio = 0.37, 95% confidence interval: 0.19 to 0.69), and the rates of soft-tissue complications (risk ratio = 0.52, 95% confidence interval: 0.33 to 0.82) favoring intramedullary nail. Intraoperative blood loss (127.2, 95% confidence interval: 34.7 to 219.7 mL) and postoperative knee pain and stiffness (relative risk = 5.6, 95% confidence interval: 1.4-22.6) showed significant differences favoring plate fixation. When combining all complication rates, the difference was risk ratio = 0.77 (95% confidence interval: 0.63 to 0.95) favoring intramedullary nail. No significant differences in radiation time, length of incision, length of hospital stay, time to return to work, time to union, the rates of healing complications or secondary procedures, ankle pain or stiffness, or functional scores were found.

CONCLUSION

This meta-analysis suggests that intramedullary nail might be slightly superior in reducing postoperative complications and result in slightly faster healing when compared to plate fixation.

Anterior knee pain and functional outcome following different surgical techniques for tibial nailing: a systematic review

Purpose

The aim of this systematic review was to compare knee pain and function after tibial nail insertion through an infrapatellar, semi-extended and suprapatellar technique.

Methods

A search was carried out to identify articles with an exact description of the method used for insertion of the tibial nail and description of the outcome parameters (knee pain or function). Data on study design, population, rate and severity of anterior knee pain and function scores were extracted. Pooled rates and scores were calculated.

Results

67 studies with 3,499 patients were included. The pooled rate of patients with anterior knee pain was 38% (95% CI 32–44) after nail insertion through an infrapatellar approach and 10% (95% CI 1–26) after insertion through a suprapatellar approach. Pooled analysis was not possible for the semi-extended technique. Knee pain scores as measured by visual analogue score (0–10) ranged from 0.2 (95% CI − 0.1–0.5) for general knee pain to 3.7 (95% CI 1.3–6.1) for pain during kneeling. Pooled estimates for the Lysholm score were 87 points (range 77–97) for the infrapatellar technique and 85 points (range 82–85) for the suprapatellar technique. Iowa Knee scores were 94 (range 86–96) and Anterior Knee Pain Scale scores were 76 (range 75–80) after infrapatellar nail insertion.

Discussion

Depending on the technique used, the proportion of patients with knee pain after tibial nailing varied between 10 and 38%. The actual measured knee pain scores were, however, surprisingly low. Knee function was good for both the infra- and suprapatellar technique.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01458-2) contains supplementary material, which is available to authorized users.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION & CONCLUSION

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

[Current treatment strategies for lower leg fractures in adults]

Shaft fractures of the tibia and fibula mainly affect younger patients and are therefore of great socioeconomic importance. Due to the high proportion of high-energy direct trauma mechanisms and the thin soft tissue covering layer of the ventromedian tibia, open factures occur in up to 39%. A structured diagnostic and therapeutic approach is essential for successful treatment. Reamed intramedullary nailing is currently the gold standard surgical procedure. The suprapatellar approach, representing an interesting alternative to the popular infrapatellar approach, postoperative complications, such as anterior knee pain as well as the management of non-unions are discussed in this article. Furthermore, the indications and the application of minimally invasive plate osteosynthesis (MIPO) and external fixators are described. Every trauma surgeon should be familiar with the etiology and the surgical treatment of compartment syndrome. A firm knowledge of the classifications of open and closed soft tissue injury is mandatory.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Semiextended Tibial Nail Insertion Using an Extraarticular Lateral Parapatellar Approach: A 24-Month Follow-up Prospective Cohort Study

OBJECTIVE

To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion.

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

PATIENTS AND METHODS

Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain.

RESULTS

Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity <10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale.

CONCLUSIONS

The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months.

LEVEL OF EVIDENCE

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

Tibial nailing using a suprapatellar rather than an infrapatellar approach significantly reduces anterior knee pain postoperatively: a multicentre clinical trial

AIMS

The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches.

PATIENTS AND METHODS

A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test - Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain.

RESULTS

A total of 53 patients were randomized to a suprapatellar approach and 42 to an infrapatellar approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared with the uninjured leg when kneeling in the suprapatellar group compared with the infrapatellar group at all timepoints at all follow-up visits. This reached significance at four months for all timepoints except 30 seconds. It also reached significance at six months at 0 seconds, and for one year at 60 seconds.

CONCLUSION

The suprapatellar surgical approach for antegrade tibial nailing is associated with less anterior knee pain postoperatively compared with the infrapatellar approach Cite this article: Bone Joint J 2019;101-B:1138-1143.

A meta-analysis of suprapatellar versus infrapatellar intramedullary nailing for the treatment of tibial shaft fractures

Background

Whether the optimal treatment for tibial shaft fractures is suprapatellar intramedullary nailing or infrapatellar approach is controversial.

Materials and methods

PubMed, Embase, Cochrane, Web of science and CNKI, Wan fang Chinese databases were retrieved from their establishment to April 26, 2017. Seven studies (three randomized and four clinical controlled trials) were included in the final analysis. This meta-analysis included 683 patients with tibial shaft fracture (suprapatellar: 341; infrapatellar: 342).

Results

There was significant difference between suprapatellar and infrapatellar approach surgery in the incidence of knee pain (P = 0.003). The malalignment of the sagittal and coronal plane in suprapatellar surgery was more serious than in the infrapatellar approach (sagittal plane: P < 0.00001; coronal plane:P = 0.07). The infrapatellar approach surgery was more time-consuming than suprapatellar surgery (P = 0.01), with no significant difference in knee function score (P = 0.35).

Conclusions

Suprapatellar intramedullary nailing reduced the incidence of knee pain and the average malalignment of fractures compared to infrapatellar intramedullary nailing. It also reduced the operation time and fluoroscopy time. The results of the study should be interpreted with caution due to the heterogeneity of the study designs.

An infrapatellar nerve block reduces knee pain in patients with chronic anterior knee pain after tibial nailing: a randomized, placebo-controlled trial in 34 patients

Background and purpose - Anterior knee pain is common after tibial nailing. Its origin is poorly understood. Injury of the infrapatellar nerve is a possible cause. In this randomized controlled trial we compared changes in knee pain after an infrapatellar nerve block with lidocaine or placebo in patients with persistent knee pain after tibial nailing. Patients and methods - Patients with chronic knee pain after tibial nailing were randomized to an infrapatellar nerve block with 5 ml 2% lidocaine or placebo (sodium chloride 0.9%), after which they performed 8 daily activities. Before and after these activities, pain was recorded using a numeric rating scale (NRS; 0-10). Primary endpoint was the change in pain during kneeling after the infrapatellar nerve block. Secondary outcomes were changes in pain after the nerve block during the other activities. Results - 34 patients (age 18-62 years) were equally randomized. A significant reduction of the NRS for kneeling pain with an infrapatellar nerve block with lidocaine was found compared with placebo (-4.5 [range -10 to -1] versus -1 [-9 to 2]; p = 0.002). There were no differences between the treatments for the NRS values for pain during other activities. Interpretation - Compared with placebo, an infrapatellar nerve block with lidocaine was more effective in reducing pain during kneeling in patients with chronic knee pain after tibial nailing. Our findings support the contention that kneeling pain after tibial nailing is a peripheral nerve-related problem.

Cognitive behavioral therapy to reduce persistent postsurgical pain following internal fixation of extremity fractures (COPE): Rationale for a randomized controlled trial

Background: Approximately half of all patients who undergo surgical repair of extremity fractures report persistent postsurgical pain (PPSP) at 1-year post-surgery. Psychological factors such as anxiety, depression, catastrophization, poor coping, high somatic complaints, and pessimism about recovery are risk factors for the development of PPSP. It is possible that interventions such as cognitive behavior therapy (CBT) that target psychological factors may reduce the incidence of PPSP in this population.

Aims: The current report reviews the role of psychological factors in the development of PPSP and discusses the rationale and protocol development for a multi-site randomized-controlled trial investigating the effectiveness of CBT in reducing PPSP in patients with surgically treated extremity fractures.

Can the use of femoral notch view alone decrease measurement error of distal interlocking screws after retrograde femoral nailing

OBJECTIVES

Determine if using different fluoroscopic views of the knee (Notch or Tangential) improves accuracy of screw lengths assessment compared to the standard posteroanterior (PA).

PARTICIPANTS AND METHODS

Orthopaedic surgeons at three ACGME-accredited residency programs were asked via survey to assess screw lengths on PA, femoral notch, and tangential radiographic views.

RESULTS

Responders correctly identified screw length using PA, femoral notch, and medial tangential views at rates of 46.75%, 52.27%, and 44.37% respectively. Respondents detected overall screw length discrepancies most accurately using the femoral notch view (Odds Ratio 1.26; 95% confidence interval: 1.07-1.47; P < 0.005). There was no statistical difference between the residents and faculty cohort in ability to detect screw length discrepancy.

CONCLUSION

Differentiating distal interlocking screw lengths on traditional imaging (AP/Notch/Tangential) is poor. The femoral notch view significantly improves accuracy in radiographic determination of screw length. The femoral notch view should be used in conjunction with the traditional PA view to maximize sensitivity and specificity for detecting prominent screws.