Suprapatellar Tibial Nailing

Arthroscopically Assisted Suprapatellar Tibial Nail Removal

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

Changes in operative treatment of tibia fractures in Finland between 2000 and 2018: A nationwide study

INTRODUCTION

Incidences of different tibia fractures are not well reported. Possible changes in the operative treatment methods have also not been studied. The aim of this nationwide registry study is to determine the incidence of operatively treated tibia fractures and investigate the possible changes in treatment methods in Finland between 2000 and 2018.

METHODS

All patients aged 16 years or older with operatively treated tibia fractures in Finland from 2000 to 2018 were included. The incidence of operatively treated proximal, diaphyseal, and distal tibia fractures per 100,000 person years by age, sex, mechanism of injury, and study year was calculated. Data were extracted from the Finnish National Hospital Discharge Register.

RESULTS

A total of 5996 proximal, 6874 diaphyseal, and 5658 distal tibia fractures were reported during the 18-year study period, resulting in incidences of 7.2/100,000, 8.1/100,000, and 6.9/100,000 person years for operatively treated proximal, diaphyseal, and distal tibia fractures, respectively. Over the study period, a clear change in fixation method in distal tibia fractures was found as plating became popular in the beginning of the 21st century. During the last 5 years of the study period, nailing and plating were equally used.

CONCLUSIONS

Operatively treated proximal tibia fractures are most common among older females while diaphyseal fractures are most frequent in young male patients. Distal tibia fractures occur most often among middle-aged people.

Removing a suprapatellar intramedullary nail via a suprapatellar approach: a retrospective cohort study

BACKGROUND

Over the last 20 years, suprapatellar (SP) intramedullary nailing has gained considerable attention for treating tibia fractures and is believed to improve fracture alignments, decrease anterior knee pain, and facilitate intraoperative fluoroscopy. However, it is associated with various concerns, including the need to make another infrapatellar (IP) incision to remove the nail.

AIMS

This study was aimed at developing a new technique for the removal of SP tibial nails through an SP approach using a cannulated extraction system. The efficiency of the novel SP approach was compared to that of the traditional IP approach for the removal of SP tibial nails.

PATIENTS AND METHODS

This was a retrospective cohort study from a prospectively collected clinical registry. The data for 69 consecutive patients who received surgery to remove a previous SP intramedullary nail using an SP approach (n = 30, SP cohort) or an IP approach (n = 39, IP cohort) were analyzed. Intra-operative evaluations included intraoperative blood loss, operation time, and changes in the surgical procedures. At six months follow-up, post-operative Lysholm knee score, visual analog scale (VAS) score, and the active range of motion (ROM) of the affected knee and complications were assessed.

RESULTS

Patients in the SP cohort exhibited an increased post-operative Lysholm knee score (β, 2.6; 95% confidence interval [CI], 0.6 to 4.6; P = 0.012), decreased post-operative VAS score (β, - 0.7; 95% CI, - 1.1 to - 0.2; P = 0.004), and increased operation time (β, 9.8 minutes; 95% CI, 5.7 to 14.0 minutes; P < 0.001) compared with those treated with the IP approach after adjustment for baseline characteristics. There were no statistically significant differences in blood loss, post-operative ROM, or complications between the two cohorts.

CONCLUSIONS

Compared with the IP technique, the SP approach for the removal of an SP tibial nail was independently associated with an increased post-operative Lysholm knee score and decreased VAS score, although the surgery was longer in duration. The novel technique offers a reliable and minimally invasive option for the removal of an SP tibial nail.

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

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.

[Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach]

Objective

To investigate the effectiveness of intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach for tibial shaft fracture.

Methods

Between July 2018 and September 2019, 22 patients with tibial shaft fracture treated with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach. There were 15 males and 7 females, with an average age of 46.4 years (range, 25-68 years). The fractures were caused by falling in 7 cases, by traffic accident in 14 cases, and by a heavy object in 1 case. Sixteen patients were closed fractures and 6 were open fractures. According to the AO classification, there were 4 cases of 42-A1 type, 2 cases of 42-A2 type, 3 cases of 42-A3 type, 3 cases of 42-B2 type, 4 cases of 42-B3 type, 2 cases of 42-C1 type, 3 cases of 42-C2 type, and 1 case of 42-C3 type. Twenty cases complicated with fibular fractures. The time from injury to operation was 2-15 days (mean, 7.5 days). The fracture healing time, complications, the incidence of anterior knee pain during the follow-up were observed; and knee joint functions were evaluated by Lysholm score at last follow-up.

Results

The operation time was 50-140 minutes (mean, 85 minutes). Two cases experienced incision exudation which healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 8-23 months (mean, 14.9 months). X-ray films reexamination showed that all fractures healed with the healing time of 12-20 weeks (mean, 14.4 weeks). Four patients (18.18%) experienced the anterior knee pain. No patellofemoral instability was observed during the follow-up period. Lysholm score of knee function was 85-100 (mean, 94.3) at last follow-up.

Conclusion

Application of the intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach is effective for tibial shaft fractures, which can not only realize the effective fixation of the fracture, but also avoid the adverse factors including re-displacement and anterior knee pain in the application of the intramedullary nailing fixation via the sub-patellar approach.

Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures

Background

This study aimed to analyze and compare the clinical and functional outcomes of distal tibia fractures treated with intramedullary nailing (IMN) using the suprapatellar (SP) and infrapatellar (IP) surgical approaches.

Methods

A retrospective analysis was performed in 63 patients with distal fractures that were treated with IMN between August 2014 and August 2018. A total of 27 and 36 patients underwent IMN using the SP and IP techniques, respectively. The surgical time, blood loss, closed reduction rate, rate of adjuvant reduction technique, fracture healing time, and complications were reviewed in this study. Anterior knee pain was assessed using the visual analog scale. The Lysholm Knee Scoring Scale and American Orthopaedic Foot and Ankle Society (AOFAS) scale were used as clinical measurements.

Results

A total of 63 patients, with a minimum follow-up of 12 months, were evaluated. The average surgical time, blood loss, rate of adjuvant reduction technique, closed reduction rate, fracture healing time, and Lysholm Knee Scoring Scale score were insignificantly different (P > 0.05) between the two groups. However, the SP approach was superior to the IP approach in terms of pain score, AOFAS score, and fracture deformity rate (P < 0.05).

Conclusions

In the treatment of distal tibia fractures, the SP IMN technique is associated with a significantly higher functional outcome, lower knee pain, and lower rate of fracture deformity than the IP IMN technique.

Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome

AIMS AND OBJECTIVES

To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months.

METHODOLOGY

In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments.

RESULTS

After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain.

CONCLUSION

We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.

Total Knee Arthroplasty After Intramedullary Tibial Nail: A Matched Cohort Study

BACKGROUND

As the use of intramedullary nails (IMNs) has become more common, there are an increasing number of patients requiring total knee arthroplasty (TKA) who have an indwelling tibial IMN. The purpose of this study is to compare implant survivorship, clinical outcomes, and complications in patients undergoing primary TKA with a history of tibial IMN to those without.

METHODS

We retrospectively identified 24 TKAs performed between 2000 and 2017 after ipsilateral tibial IMN. Patients were matched 1:2 to patients undergoing primary TKA without history of tibial IMN based upon age, gender, body mass index, and year of surgery. Mean follow-up was 7 years.

RESULTS

The 10-year survivorship free of any revision was 100% for the tibial IMN cohort, and 96% for the control cohort, while the 10-year survivorship free of any reoperation was 91% and 89%, respectively (P = .72). Patients with a history of tibial IMN had similar Knee Society Scores to matched controls at 2 years (P = .77) and 5 years (P = .09). Acquired idiopathic stiffness trended toward being more common (17% vs 6%, P = .21) and operative time trended toward being longer (135 vs 118 min, P = .07) when the tibial IMN was removed, but there was no overall difference in complication rate between cohorts.

CONCLUSIONS

To our knowledge, this is the first report of primary TKA in patients with a history of ipsilateral tibial IMN. Compared to a matched cohort of patients without tibial IMN, these patients have similar outcomes in regards to implant survivorship, clinical outcomes, and risk of complications.

LEVEL OF EVIDENCE

Therapeutic Level III.