Decrease surgery time by using an alternative lateral parapatellar approach for tibia shaft fracture nailing

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.

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.

Combination of radiographic apparent bone gap and nonunion risk determination score improves accuracy of prediction of tibial shaft delayed union

BACKGROUND

There is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union.

METHODS

The inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union.

RESULTS

The union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively.

CONCLUSIONS

The combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.

Comparison of Medial Parapatellar and Transpatellar Tendon Approach in Intramedullary Interlocking Nailing for Tibial Fracture: A Retrospective Analysis

Introduction

Tibial fractures are one of the most common traumatic fractures, particularly in automobile accidents. Percutaneous reduction with conventional reduction forceps and un reamed intramedullary nailing, transpatellar, and medial parapatellar tendon approaches are all used, but tibial intramedullary nails are still primarily inserted through a transpatellar tendon splitting or medial parapatellar tendon approach.

Objective

The aim and objectives of this study are to assess the mean pain score after nailing for a tibial fracture using a medial parapatellar versus a transpatellar tendon method retrospectively in order to enhance operational planning.

Materials and methods

This is a retrospective study that took place in a UK level 1 trauma center. Data from 60 patients were included between February 2019 and February 2020. An equal number of patients were selected for both approaches to maintain accuracy. The advanced trauma life support (ATLS) protocol was used to handle all of the patients in both groups in order to rule out any other injuries or fractures, after which they were scheduled for surgery after stabilization. They were subsequently evaluated during a three-month follow-up in an outdoor clinic, where they were given a pain score using the visual analogue score (VAS) while moving their knee joints. The mean pain score was differentiated by age, gender, body mass index (BMI), injury side, and injury type.

Results

Patients were divided into groups based on their ages. Patients in the transpatellar tendon group were 32.83±5.13 years old, whereas those in the medial parapatellar tendon group were 31.4 ±5.42 years old. The gender distribution of the patients revealed that the majority of the patients in both groups were male. In both groups, the left side was the most usually affected. The difference between the two groups' mean pain scores at three months was substantially lower in the medial parapatellar approach (p=0.005).

Conclusion

For patients having intramedullary nailing for tibial fractures, the medial parapatellar route is associated with a lower mean pain score than the transpatellar route. As a result, we may use this method in these individuals regularly.

Intramedullary tibia nailing with external fixation

PURPOSE

This study introduces an intramedullary nailing technique with external fixation and aims to determine the safest position of Schanz screws for this technique.

METHODS

Patients undergoing intramedullary nailing were evaluated by computed tomography to assess the anteroposterior (AP) length of the medullary canal and the distance between the posterior cortex and the posterior border of the nail at the level of interest in the proximal and distal tibia. In this cadaveric study, screws were inserted at the level of interest, followed by a determination of the anatomical relationship between inserted screws and nearby neurovascular structures.

RESULTS

The safe area for inserting Schanz screws in the medial to lateral direction in the proximal tibia was found to be 1.5-4.5 cm distal to the knee joint line on the AP view, 1 cm anterior to the posterior cortex at the distal 4.5 cm level, and ≤ 24 mm from the posterior cortex on the lateral view. In males, the area 1.5-3.0 cm proximal to the tibial plafond and 0.5 cm anterior to the posterior cortex on the lateral view was found to be a safe zone. However, in females, the safe zone was defined as an area 1.5 cm proximal to the tibial plafond and just anterior to the posterior cortex.

CONCLUSION

This study defined the safe zones of Schanz screws for intramedullary nailing with an external fixator. These safe zones would be helpful for external fixation during intramedullary tibia nailing.