Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome

Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function

BACKGROUND

The primary aim of this study was to compare the radiographic parameters (nail insertion-point accuracy [NIPA] and fracture malalignment) of patients who had undergone tibial intramedullary nailing via the suprapatellar (SP) and infrapatellar (IP) approaches. The secondary aims were to compare clinical outcomes and patient-reported outcomes (PROs) between these approaches.

METHODS

All adult patients with an acute tibial diaphyseal fracture who underwent intramedullary nailing at a single level-I trauma center over a 4-year period (2017 to 2020) were retrospectively identified. The nailing approach (SP or IP) was at the treating surgeon's discretion. Intraoperative and immediate postoperative radiographs were reviewed to assess NIPA (mean distance from the optimal insertion point) and malalignment (≥5°). Medical records and radiographs were reviewed to evaluate the rates of malunion, nonunion, and other postoperative complications. The Oxford and Lysholm Knee Scores (OKS and LKS) and patient satisfaction (0 = completely dissatisfied, 100 = completely satisfied) were obtained via a postal survey at a minimum of 1 year postoperatively.

RESULTS

The cohort consisted of 219 consecutive patients (mean age, 48 years [range, 16 to 90 years], 51% [112] male). There were 61 patients (27.9%) in the SP group and 158 (72.1%) in the IP group. The groups did not differ in baseline demographic or injury-related variables. SP nailing was associated with superior coronal NIPA (p < 0.001; 95% confidence interval [CI] for IP versus SP, 1.17 to 3.60 mm) and sagittal NIPA (p < 0.001; 95% CI, 0.23 to 0.97 mm) and with a reduced rate of malalignment (3% [2 of 61] versus 11% [18 of 158] for IP; p = 0.030). PROs were available for 118 of 211 patients (56%; 32 of 58 in the SP group and 86 of 153 in the IP group) at a mean of 3 years (range, 1.2 to 6.5 years). There was no difference between the SP and IP groups in mean OKS (36.5 versus 39.6; p = 0.246), LKS (71.2 versus 73.5; p = 0.696), or satisfaction scores (81.4 versus 79.9; p = 0.725).

CONCLUSIONS

Compared with IP nailing, SP nailing of tibial shaft fractures was associated with superior NIPA and a reduced rate of intraoperative malalignment but not of malunion at healing. However, the superior NIPA may not be clinically important. Furthermore, there were no differences in PROs at mid-term follow-up.

LEVEL OF EVIDENCE

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

The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles

PURPOSE

This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes.

METHODS

PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised.

RESULTS

Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes.

CONCLUSION

The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

Comparing Minimally Invasive Percutaneous Plate Osteosynthesis With Interlocking Intramedullary Nail Fixation for the Management of Adult Extra-Articular Distal Tibial Fractures: A Comprehensive Systematic Review and Meta-Analysis

Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPO and interlocking IMN techniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.

No Difference in Short-Term Complications following Treatment of Closed Tibial Shaft Fractures with Intramedullary Nailing versus Plate Fixation

Objectives

Tibial shaft fractures are treated with both intramedullary nailing (IMN) and plate fixation (ORIF). Using a large national database, we aimed to explore the differences in thirty-day complication rates between IMN and ORIF.

Methods

Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had undergone either tibial IMN or ORIF for closed fractures from 2010 to 2018 were identified using current procedural terminology (CPT) codes. After excluding all patients with open fractures, the propensity score was matching. Univariate and multivariate logistic regressions were used to identify risk factors associated with the thirty-day incidence of complications in the two cohorts.

Results

A total of 5,400 patients were identified with 3,902 (72.3%) undergoing IMN and 1,498 (27.7%) ORIF. After excluding any ICD-10 diagnosis codes not pertaining to closed, traumatic tibial shaft fractures, 2,136 IMN and 621 ORIF cases remained. After matching, the baseline demographics were not significantly different between the cohorts. Following matching, the rate of any adverse event (aae) did not differ significantly between the IMN (7.08% (n = 44)) and ORIF (8.86% (n = 55)) cohorts (p=0.13). There was also no significant difference in operative time (IMN = 98.5 min, ORIF = 100 min; p=0.3) or length of stay (IMN = 3.7 days, ORIF = 3.3 days; p=0.08) between the cohorts.

Conclusion

There were no significant differences in short-term complications between cohorts. These are important data for the surgeon when considering surgical management of closed tibial shaft fractures.

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.

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.

Tibial Intramedullary Nailing by Suprapatellar Approach: Is It Quicker and Safer?

Background

With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails.

Methods

This is a retrospective cohort analysis of 34 SP tibial nails over three years vs 24 IP tibial nails over a similar time frame. We compared total radiation dose (TRD), patient positioning time (PPT), fracture healing and follow up time. Knee pain in the SP group was evaluated utilising the Hospital for Special Surgery (HSS) Knee Injury and Osteoarthritis Outcome Score (KOOS).

Results

Fifty-eight patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78 cGy (range: 11.60-156.01 cGy) vs 121.09 cGy (range: 58.01-18.03 cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow up was 5.5 months vs 11 months in the IP and SP groups, respectively. Mean KOOS was 7 (range: 0-22) at six months for the SP group.

Conclusion

The semi-extended position (SP group) leads to reduced TRD because of ease of imaging. Patients showed improved outcomes with shorter follow up and fracture union in all patients (SP group). The KOOS revealed that SP nail patients had minimal pain and good knee function. This study establishes a management and patient-reported outcome measures (PROMs) baseline for ongoing evaluation of SP nails.

Visualising knee loading patterns during kneeling and the development of a laboratory-based adaptation of the Aberdeen Weight-Bearing Test (Knee)

BACKGROUND

Information regarding the loading of key anatomical structures of the knee during kneeling would enhance existing functional tests, yet current visualisation methods are limited and require further development.

AIMS

(1) Develop a knee loading visualisation technique to investigate loading patterns of the knee during kneeling; and (2) determine the utility of the technique in combination with vertical ground reaction forces and centre of pressure data in the lab-based Aberdeen Weight-Bearing Test (Knee) by assessing their reliability.

METHODS

Fourteen healthy participants conducted kneeling tasks with and without knee pads across two testing sessions. Eight force-sensitive resistors were affixed to the right knee throughout different kneeling tasks: upright kneeling, and reaching forward, back, left, and right. A photo of the force-sensitive resistor configuration was used to generate participant-specific heat maps of knee loading. Two in-ground force platforms were used to measure vertical ground reaction forces and centre of pressure.

RESULTS

The inferior patella tendon showed the highest proportion of activation during both bare and knee pad kneeling for all kneeling tasks. Knee pads reduced the repeatability of knee loading patterns. Force-sensitive resistor activation and vertical ground reaction force components of the lab-based Aberdeen Weight-Bearing Test (Knee) were shown to be reliable, whereas the centre of pressure data was unreliable.

CONCLUSION

We have developed a lab-based technique for visualising knee loading using force-sensitive resistors. The combination of force-sensitive resistor activation and vertical ground reaction force data provides valuable insights into both the magnitude and locations of applied loads throughout kneeling.

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.

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.

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study

Objective

To develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.

Methods

A retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.

Results

All 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.

Conclusion

The parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.

Complications of Hardware Removal

BACKGROUND

While hardware removal may improve patient function, the procedure carries risks of unexpected outcomes. Despite being among the most commonly performed orthopaedic procedures, scant attention has been given to its complication profile.

METHODS

We queried the American Board of Orthopaedic Surgery (ABOS) de-identified database of Part II surgical case lists from 2013 through 2019 for American Medical Association Current Procedural Terminology (CPT) implant-removal codes (20680, 20670, 22850, 22852, 22855, 26320). Hardware removal procedures that were performed without any other concurrent procedure ("HR-only procedures") were examined for associated complications.

RESULTS

In the 7 years analyzed, 13,089 HR-only procedures were performed, representing 2.1% (95% confidence interval [CI], 2.1% to 2.2%) of the total of 609,150 surgical procedures during that period. A complication was reported to have occurred in association with 1,256 procedures (9.6% [95% CI, 9.1% to 10.1%]), with surgical complications reported in association with 1,151 procedures (8.8% [95% CI, 8.3% to 9.3%]) and medical/anesthetic complications reported in association with 196 procedures (1.5% [95% CI, 1.3% to 1.7%]). Wound-healing delay/failure (2.1% [95% CI, 1.8% to 2.3%]) and infection (1.6% [95% CI, 1.4% to 1.8%]) were among the most commonly reported complications after HR-only procedures, but other serious events were reported as well, including unexpected reoperations (2.5% [95% CI, 2.2% to 2.7%]), unexpected readmissions (1.6% [95% CI, 1.4% to 1.8%]), continuing pain (95% CI, 1.2% [1.0% to 1.4%]), nerve injury (0.6% [95% CI, 0.4% to 0.7%]), bone fracture (0.5% [95% CI, 0.4% to 0.6%]), and life-threatening complications (0.4% [95% CI, 0.3% to 0.5%]).

CONCLUSIONS

Hardware removal is one of the most commonly performed orthopaedic procedures and was associated with an overall complication rate of 9.6% (95% CI, 9.1% to 10.1%) in a cohort of recently trained orthopaedic surgeons in the United States. Although specific complications such as infection, refractures, and nerve damage were reported to have relatively low rates of occurrence, and associated life-threatening complications occurred rarely, surgeons and patients should be aware that hardware removal carries a definite risk.

LEVEL OF EVIDENCE

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

Patella baja after intramedullary nailing of tibial fractures, using an infrapatellar/transtendinous approach, predicts worse patient reported outcome

Purpose

After intramedullary nailing of tibial shaft fractures using an infrapatellar/transtendinous approach, several patients suffer anterior knee pain. We suspect that the approach is associated with soft tissue scars and the development of a postoperative patella baja. The goal of the study is to investigate whether the development of patella baja is associated with worse subjective outcomes.

Methods

We retrospectively analyzed all patients in our orthopedic trauma department between 2011 and 2020 who underwent tibial fracture fixation via intramedullary nailing via an infrapatellar/transtendinous approach. Pre- and postoperative lateral knee x-rays were evaluated by measurement of the Insall-Salvati Index, and nail tip position. All patients were asked to answer the self-assessment Kujala questionnaire and Lysholm questionnaire.

Results

We included 78 patients (age: 44 ± 18 years) with a minimum follow-up of 12 months. Mean follow up was 59 ± 25 months. We included 50 male and 28 female patients. Patella baja detected by Insall-Salvati Index could be observed in 8 (10.3%) patients. Patients with patella baja showed significant worse function measured by the Kujala score 54 ± 18 vs. 80 ± 14 (p < 0.01). Likewise, Lysholm score did show significant differences between both groups (60 ± 24 vs. 86 ± 11; p < 0.01). Nail tip position was not associated with worse subjective function.

Conclusions

Patella baja in patients after tibial intramedullary nailing via an infrapatellar/transtendinous approach, is associated with worse subjective function and increased pain.

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.

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.

Pulsed electromagnetic fields after intramedullary nailing of tibial fractures: a case control study

PURPOSE

To compare clinical and functional outcomes of two groups of patients undergoing reduction and nailing fixation for diaphyseal fractures of the tibia with (PEMF group) and without (control group) post-operative pulsed electromagnetic field (PEMF) application.

METHODS

This is a retrospective study on 50 patients (mean age 43.3 years, 28 males and 22 females) with diaphyseal tibial fractures managed between 2017 and 2019. Twenty-five patients underwent reduction, nailing fixation, and PEMF application post-operatively (PEMF group) and 25 patients underwent nailing fixation. Radiographic imaging assessment was performed every month until fracture healing had been evident. Use of analgesics, fracture healing time, post-operative lower limb alignment, and post-operative complications were recorded. Patients were asked about return to preinjury activity. All patients were assessed at 3 months and at an average follow-up of 13 months. The VAS scale and Johner-Wruhs criteria were used for pain assessment and functional recovery, respectively.

RESULTS

Comparing groups, VAS values were significantly lower in the PEMF group at three months and comparable at one year. The patients in the PEMF group took an average of 4.1 months to resume their preinjury activities, and control patients took an average of 5.3 months (P < 0.0001). According to the Johner-Wruhs score, the effective rate was 100% (25/25) in the PEMF group and 92% (23/25) in the control group (P = 0.14).

CONCLUSIONS

PEMF application after intramedullary nailing is safe and reduces post-operative pain, use of analgesics, and the time of healing fracture. At one year, there is no difference in outcome measures, regardless of PEMF application.

Results following prolonged recovery show satisfactory functional and patient-reported outcome after intramedullary nailing of a tibial shaft fracture: a prospective 5-year follow-up cohort study

INTRODUCTION

Although a large number of previous studies have investigated the outcome in patients following tibial shaft fractures, the literature provides limited information on prospectively reported patients with mid- to long-term follow-up. The present study aimed to investigate prospectively the 5-year development in patient-reported quality of life after intramedullary nailing of a tibial shaft fracture.

MATERIAL AND METHODS

The design was a prospective, 5-year follow-up cohort study. Quality of life (QOL) was measured with the questionnaire Eq5d-5L and compared to the 1-year outcome reported by the same patients. Secondary outcome measurements were the Knee Injury and Osteoarthritis Outcome Score (KOOS), recordings of pain, gait and muscle strength.

RESULTS

Twenty-nine patients were eligible for participation. Mean patient age at the time of the 5-year follow-up was 46.3 years. The 5-year postoperative mean Eq5d-5L index was 0.864 (95% CI 0.809-0.918). The mean Eq5d-5L VAS was 88.4 (95% CI 83.4-93.5). Compared with the same patients' Eq5d-5L index scores at the 1-year follow-up (0.784), a significant increase was observed (P = 0.014). A comparison to the Danish Eq.5D reference population showed no statistically significant difference.

CONCLUSIONS

Patient-reported quality of life among patients treated with intramedullary nailing following a tibial shaft fracture increased significantly between the 1-year and 5-year follow-up. In contrast to the 1-year patient-reported quality of life, results are comparable to those of a reference population at the 5-year follow-up. In a clinical setting, these results highlight that patients may expect a prolonged period to recover. However, of most importance is that patients can expect a satisfactory outcome years after fracture and treatment.

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.

Implant removal of osteosynthesis. Results of a survey among Spanish orthopaedic surgeons

INTRODUCTION

The indications on extraction of osteosynthesis material are not well defined in the current literature deriving in relative indications, depending on experiences, customs or patient's request. The aim of this article is to assess the beliefs, indications, usual practice and perceived complications of surgeons in Spain regarding on extraction of osteosynthesis material.

METHODS

We conducted a questionnaire of 44 questions covering general demographics, general and subjective opinion on implant removal, specific attitudes by implant type and anatomical location, and personal habits.

RESULTS

164 questionnaires were received. The most frequent indications are patellar and olecranon cerclage wires and elastic nails in children. 56% remove the implant at the patient's request, 31% always remove it in children, 28% do it in asymptomatic patients to avoid possible surgical problems, 14% to avoid a possible peri-implant fracture and 9% by simple preference. The most frequent intraoperative complications are surgery longer than expected, bone growth over the implant, rounded screw head core, cold fusion, difficulty in finding the implant and impossibility to remove part of the implant. The most frequent postoperative complication was persistence of symptoms 39.8%.

CONCLUSION

The results provide information to advise the patient regarding the expected clinical outcome and intra and postoperative complications. The surgeon should cautiously indicate extraction in the asymptomatic patient given the high rate of complications.

Semi-extended intramedullary nailing of the tibia using an infrapatellar approach: a retrospective cohort study

PURPOSE

The semi-extended tibial intramedullary nailing method would enable easier and improved reductions for tibial fractures as well as facilitate fluoroscopic imaging; however, its in-articular nature remains controversial. The aim of this study was to compare the clinical and functional outcomes of the semi-extended infrapatellar (SEIP) approach and hyper-flexed infrapatellar (HFIP) approach for intramedullary nailing to treat tibial shaft fractures.

METHODS

This study involved the retrospective analysis of the medical records of patients with tibial shaft fractures that were fixed through either the SEIP approach or the HFIP approach of intramedullary nailing and who were admitted to a level 1 trauma centre. The minimum patient follow-up period was 12 months and the clinical and functional outcomes were estimated at the 12-month visit.

RESULTS

Of the 80 patients whose medical records were analyzed, 40 (50%) underwent SEIP nailing and the remaining 40 (50%) underwent the traditional HFIP nailing. Compared with the HFIP group, patients in the SEIP group had a higher Lysholm knee score (median, 92 [interquartile range, 88-95] vs median, 88 [interquartile range, 81-92]; p = .01), a shorter intra-operative fluoroscopy time (median, 93 [interquartile range, 78-105] s, vs median, 136 [interquartile range, 110-157] s; p < .001), and operation time (mean, 88.1 [SD, 17.8] min vs mean, 98.7 [SD, 19.3] min; p = .01). The VAS score was significantly lower in the SEIP group (median, 0; interquartile range, 0-0) than in the HFIP group (median, 0; interquartile range, 0-2) (p = .03). There were two cases (5%) in the SEIP group and 10 cases (25%) in the HFIP group of moderate AKP (p = .03). Meanwhile, there was no significant difference in malalignment, nonunion, delayed union, infection, and other complications, as well as SF-36 physical and mental scores.

CONCLUSION

We found that the SEIP approach to tibia intramedullary nailing was superior to the HFIP approach based on the intra-operative and post-operative outcomes. Thus, this novel technique provides an infrapatellar option for semi-extended tibial nailing.

Long-Term Patient-Reported Knee Outcomes After Suprapatellar Intramedullary Tibial Nailing

BACKGROUND

Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing.

METHODS

Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4-9 years) follow-up.

RESULTS

The median TLKS was 98 (interquartile range, 85-100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1-65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker's compensation.

CONCLUSION

At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Minimally invasive plate osteosynthesis (MIPO) for mid-shaft fracture of the tibia (AO/OTA classification 42): A retrospective study

BACKGROUND

There is abundance of literature regarding the treatment of tibial mid-shaft fracture, and intramedullary nailing (IMN) is described as the treatment of choice. However, problems such as malunion and knee pain are known disadvantages of this approach. Minimally invasive plate osteosynthesis (MIPO) technique is another treatment option for tibial mid-shaft fracture.The purpose of this study is to evaluate the clinical, radiological results, and complication rates of tibial mid-shaft fractures treated with MIPO technique.

MATERIALS AND METHOD

Thirty-seven skeletally mature patients who underwent MIPO for a mid-shaft fracture of tibia (AO/OTA classification 42) from June 2016 to May 2018 were retrospectively reviewed. A total of 37 patients (12 females, 25 males) with a mean age of 52.7 years (range 28-78 years) were included. The clinical and radiological outcomes, such as the Jeju Lower Extremity Trauma Scale (JLETS), time to callus formation, time to bony union, and complications such as delayed union, malunion, nonunion, and infection were assessed.

RESULTS

Bony union was achieved in all cases but one (36 cases). Average callus formation was observed in 10.7 (6.5-14.5) weeks. The average time to union was 19.8 (11.5-26.5) weeks. The average JLETS score was 46.9 (40-53) point. Malunion deformities were observed in 3 cases (8.1%). Two superficial infection cases all resolved spontaneously. There was no statistically significant difference in clinical and radiographic outcomes by different AO/OTA fracture types.

CONCLUSION

The MIPO technique with locking compression plate provides stable fixation and satisfactory clinical and radiological results for mid-shaft fractures of tibia irrespective of the fracture type. Future study should aim to compare MIPO and IMN cases directly to clarify the differences and similarities between the two treatment modalities.

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.

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.

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.

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.

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.

Infrapatellar nerve damage : A neglected cause of severe localized leg pain

A small portion of patients suffer from severe knee pain following previous knee surgery or a trauma. Awareness among traumatologists regarding a neuropathic origin of this persistent knee pain is poor. Ongoing pain close to the knee may be caused by damage of the infrapatellar nerve (IN). This branch of the saphenous nerve is purely sensory and is at risk for iatrogenic damage due to its superficial medial course. Once recognized using simple tests during physical examination, a variety of treatment modalities may be proposed. However, a standard treatment algorithm was hitherto absent. This study includes 15 patients having IN damage who were offered a step-up regimen including lidocaine injections, pulsed radiofrequency (PRF) or neurectomy. Success (>50% drop in numeric rating scale pain score) was attained in 11 (73% success rate, 9 month median follow-up). The aim of this contribution is to increase knowledge regarding this illusive entity and to discuss the efficacy of our treatment protocol.

[Infrapatellar nerve damage : A neglected cause of severe localized leg pain-German version]

A small portion of patients suffer from severe knee pain following previous knee surgery or a trauma. Awareness among traumatologists regarding a neuropathic origin of this persistent knee pain is poor. Ongoing pain close to the knee may be caused by damage of the infrapatellar nerve (IN). This branch of the saphenous nerve is purely sensory and is at risk for iatrogenic damage due to its superficial medial course. Once recognized using simple tests during physical examination, a variety of treatment modalities may be proposed. However, a standard treatment algorithm was hitherto absent. This study includes 15 patients having IN damage who were offered a step-up regimen including lidocaine injections, pulsed radiofrequency (PRF) or neurectomy. Success (>50% drop in numeric rating scale pain score) was attained in 11 (73% success rate, 9 month median follow-up). The aim of this contribution is to increase knowledge regarding this illusive entity and to discuss the efficacy of our treatment protocol.

Comparison of 3 Treatment Methods for Distal Tibial Fractures: A Network Meta-Analysis

Background

The choice of optimal internal fixation device for distal tibial fractures remains controversial. The purpose of our study was to evaluate the effectiveness and safety of open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and intramedullary nailing of distal tibial fractures in adults using network meta-analysis of data from clinical trials.

Material/Methods

The studies were abstracted from MEDLINE, EMBASE, CNKI, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials meeting inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 13.0 (Stata Corporation, College Station, Texas, USA).

Results

Eleven randomized controlled trials were included. The total number of participants was 710 and the studies were published between 2005 and 2017. There were no significant differences in rates of delayed union, nonunion, or malunion among the various treatments (all p>0.05). The intramedullary nailing group had a lower incidence of wound complications than did the open reduction and internal fixation group and minimally invasive percutaneous osteosynthesis technique group. The SUCRA probabilities were 28.6% for ORIF, 98.4% for IMN, and 22.9% for MIPPO.

Conclusions

Given the superior results for intramedullary nailing in terms of wound complications, we recommend this procedure for treatment of distal tibial fractures. More RCTs focused on distal tibial fractures are needed to support the current evidence.

Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia

OBJECTIVE

To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I trauma center.

PATIENTS/PARTICIPANTS

All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours.

INTERVENTION

Intramedullary nailing of a tibia fracture with either the SP or IP approach.

MAIN OUTCOME MEASUREMENTS

Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful.

RESULTS

The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45).

CONCLUSIONS

In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up.

LEVEL OF EVIDENCE

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

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.

Nonoperative Management of Proximal Tibiofibular Joint Synostosis after Tibial Intramedullary Nailing

We report the case of a 28-year-old male semiprofessional basketball player who presented to an outside hospital with nonhealing stress fractures for which he underwent tibial intramedullary nailing (IMN). Two weeks after surgery, he developed pain proximal and lateral to the knee. As he returned to play, the pain worsened with jumping and lateral movement and improved with rest. He presented to our hospital one year after the operation with the same unresolved pain. Imaging one year after the surgery revealed proximal tibiofibular joint (TFJ) synostosis aligned with the drill path. Literature review showed that rare noncongenital cases of proximal TFJ synostosis cases were most often treated nonoperatively. However, two cases involved the removal of excessively protruding screws and two cases involved bone resection that resolved painful disruption of other joints, such as the ankle. The current patient had proper implant positioning and no other impacted joints, so he was managed without operative intervention. By the final 16-month postoperative follow-up, his symptoms had resolved completely. Although an unusual occurrence with limited data, we recommend nonoperative management for proximal TFJ synostosis caused by tibial nailing if implants are properly positioned and no other joints are affected.

Do the Loss of Thigh Muscle Strength and Tibial Malrotation Cause Anterior Knee Pain after Tibia Intramedullary Nailing?

Purpose

Anterior knee pain (AKP) is a common complication after tibia intramedullary nailing surgery, but yet the etiology is not fully revealed. Our study had two hypotheses. The first one is "after tibia intramedullary nailing with transtendinous approach, thigh muscles strength decreases and this loss of muscle strength causes AKP." Secondly, "lower extremity rotational profile is affected after tibia intramedullary nailing." Methods. Our study was planned retrospectively and included 40 patients, who underwent tibia intramedullary nailing surgery. Mean follow-up time was 22.5 months. Tegner Lysholm knee scoring scale was applied to evaluate postoperative functional outcomes of all patients. Isometric muscle strengths of bilateral knee extensor and flexor muscle groups were compared with hand-held dynamometer. In addition, bilateral lower extremity Staheli rotational profile angles (foot progression angle (FPA), thigh-foot angle (TFA), and transmalleolar angle (TMA)) were compared.

Results

Lysholm knee score was evaluated as excellent in 28 patients. AKP were detected in 15 patients and there was no significant difference between the injured limb with contralateral quadriceps mean muscle strength (injured limb mean (ILM) = 201.97 Newton (N) - contralateral mean (CM) = 205.4 N). However, there was a significant difference (p<0,05) between injured limb with contralateral extremity hamstring mean muscle strength (ILM = 153.2 N- CM=158.95 N). Although there was a significant difference between the two extremities' rotational profile angles, there was no significant correlation between the rotational profile angles and knee pain.

Conclusion

As a result of our study, AKP appears to be significantly related to the loss of hamstring muscle strength. We suppose that hamstring exercises will gain importance in rehabilitation programs of tibia intramedullary nailing surgery in future.

Improved Outcomes With Semi-extended Nailing of Tibial Fractures? A Systematic Review

OBJECTIVE

To systematically review the existing literature to determine whether knee pain and function following intramedullary nailing of tibial shaft fractures differs significantly by surgical technique-specifically with semi-extended nailing versus traditional infrapatellar approaches.

DATA SOURCE

A comprehensive search of PubMed/MEDLINE, EMBASE, and the Cochrane Database was conducted on August 15, 2018.

STUDY SELECTION

We included level I-level III studies that examined outcomes of tibial intramedullary nailing utilizing a semi-extended technique. All included studies reported Lysholm Knee Scores with minimum clinical follow-up of 1 year. Non-English language literature and studies older than 20 years were not included.

DATA EXTRACTION

Data from each study were independently recorded by 2 reviewers.

DATA SYNTHESIS

Two prospective, randomized trials and 4 retrospective cohort studies were included in this review. A meta-analysis was not performed.

CONCLUSIONS

Evidence comparing postoperative knee pain and functional outcomes between semi-extended and traditional infrapatellar nailing is limited. Available literature suggests satisfactory outcomes with semi-extended nailing. The highest level of evidence available does indicate improved pain and function with semi-extended nailing as compared to infrapatellar nailing. Additional research may be required to reach consensus conclusions.

LEVEL OF EVIDENCE

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

A Comparison of the Open Semi-extended Parapatellar Versus Standard Entry Tibial Nailing Techniques and Knee Pain: A Randomized Controlled Trial

OBJECTIVE

To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK).

DESIGN

Randomized controlled trial.

SETTING

Level 1 trauma center.

PATIENTS

Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study.

INTERVENTION

Patients were randomized to treatment with either a SEK or an FK technique.

MAIN OUTCOME

The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain.

RESULTS

Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK - FK): 0.29, 90% confidence interval: -4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK - FK): 0.2, 90% confidence interval: -3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren-Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores.

CONCLUSIONS

The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique.

LEVEL OF EVIDENCE

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

Knee Pain and Functional Scores After Intramedullary Nailing of Tibial Shaft Fractures Using a Suprapatellar Approach

OBJECTIVES

To evaluate the effects of intramedullar nailing of the tibia using a suprapatellar (SP) approach with respect to pain and function of the knee.

DESIGN

Prospective clinical investigation.

SETTING

Academic level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-one patients with tibial shaft fractures (Orthopaedic Trauma Association 42A-B-C) with a minimum of 12-month follow-up.

INTERVENTION

Locked intramedullary nailing using a SP approach.

MAIN OUTCOME MEASUREMENTS

Radiographic evaluation for nail position proximally, tibial shaft alignment and union, anterior knee pain using the visual analog scale, and knee function evaluation using the Lysholm and SF-36 scores. Examination of intra-articular damage was performed using intraoperative patellofemoral arthroscopy before and after nail insertion.

RESULTS

The mean age of the patients was 35.4 ± 12.4 years (range, 18-63 years), and the mean follow-up period was 15.62 ± 3.2 months (range, 12-21 months). The visual analog scale score for anterior knee pain was a mean of 1.0 ± 1.3 (range, 0-4). The SF-36 physical score was mean 45.1 ± 9, and the SF-36 mental score was a mean of 51.7 ± 9.9. The knee joint range of movement was measured as 133.1 ± 87 degrees on the affected extremity side and 134.05 ± 8.4 degrees on the unaffected side. The mean Lysholm knee score was 95.76 ± 4. No intra-articular pathology was seen on arthroscopy after nail insertion.

CONCLUSIONS

The SP approach for intramedullar nailing for tibial shaft fractures was not associated with either anterior knee pain or functional limitations of the knee in our series.

LEVEL OF EVIDENCE

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

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

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

Surgical technique for biological fixation of closed segmental tibial fractures by the Less Invasive Stabilization System (LISS)

INTRODUCTION

This prospective case series study aimed to assess the value of the Less Invasive Stabilization System (LISS) to treat closed Segmental Tibial Fractures (STFs) using a proposed surgical technique.

MATERIALS AND METHODS

Between August 2010 and January 2014, 21 consecutive recently (within 1 week) closed STFs that matched the inclusion criteria were enrolled. Patients were treated with the 13-hole LISS plate. All patients were followed up every 2 weeks for the first 2 months, then every month for the rest of the first 6 months and then every 6 months thereafter. Patients were assessed radiologically during the follow-up appointments and clinically at the final visit by the Lower Extremity Functional Scale (LEFS) to evaluate the result.

RESULTS

The mean time to union of the proximal fracture was 15.72 ± 2.78 (range: 12-20) weeks and for the distal fracture was 20 ± 2.22 (range: 16-24) weeks, excluding delayed union in three patients. All patients except the three showed radiological observable callus in a mean duration of 4.95 (range: 3-7) weeks. The mean final follow-up LEFS was 72.4 (range: 60-80).

CONCLUSION

The mean time to union of the proximal fracture was shorter than the distal fracture. The use of LISS to treat closed STFs using the proposed surgical technique has proved to give favorable results. Further studies using the described technique are needed to justify the achieved results.

LEVEL OF EVIDENCE

IV (Prospective case series).

Ultrasonographic comparison of bilateral patellar tendon dimensions in patients treated via intramedullary tibial nailing using a transpatellar approach

Objective

One of the most common complications following intramedullary nailing of a tibial shaft fracture is anterior knee pain. The etiology of pain remains unclear. Patellar tendon entry point is the most suspected reason for anterior knee pain. This study, sonographically examined the patellar tendons of patients treated via intramedullary nailing.

Methods

Thirty-two patients with a tibial shaft fracture requiring intramedullary nailing via a transpatellar approach were included in the study. After all patients were grouped by reference to the presence of anterior knee pain, bilateral patellar tendon ultrasonography was performed.

Results

Thirty-two patients were included in the study. Patients were measured postop average in 38.3 months (10th months - 84th months). It was determined that 10 patients of total 32 (31.3%) had anterior knee pain. There were no statistically differences between study groups in the length of patellar tendon. In the painless group; patellar tendon was wider and thicker in the operated side than the non operated side. The mean differences in the thickness between operated side versus non – operated side of the painless group were 5.3 ± 1.8 in the operated side and 3.9 ± 1.4 in the non – operated side (p = 0.007 < 0.05). The corresponding values for width of the patellar tendon was 29.6 ± 3.3 in the operated side and 27.6 ± 3.8 in the non – operated side (p = 0.007 ˂ 0.05). As a result, there were no statistically significant differences between width and thickness of the patellar tendons in the painful group, on the contrary, in the painless group; patellar tendons were wider and thicker in the operated side than those in the non - operated side. Mean values for thickness of the operated and non-operated side were 5.9 ± 2.3 and 4.2 ± 2.0, respectively (p = 0.059 > 0.05). Mean values for width of the operated and non-operated side were 30.2 ± 4.5 and 28.5 ± 4.0, respectively (p = 0.103 > 0,05).

Conclusion

Based on the ultrasonographic investigation of their patellar tendons after intramedullary nailing of a tibial shaft fracture, in the painless patients group; the patellar tendon was wider and thicker in the operated side than the non – operated side, however, in the painful patients there were no statistically significant differences between this parameters. Although the number of patients was not sufficient to conclude precise relation between patellar tendon entry point and anterior knee pain, we determined that thicker and wider tendon might be less related to anterior knee pain.

Level of evidence

Level IV, therapeutic study.

Importance of Mechanoreceptors and Other Neural Structures Within the Anterior Intermeniscal Ligament in the Etiology of Anterior Knee Pain After Tibial Nailing

BACKGROUND

Anterior knee pain is the most common complication after intramedullary tibial nailing. The cause is often multifactorial and varies among individuals. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible source of postsurgical anterior knee pain. Although there is a certain ambiguity regarding the importance and function of the AIL, neural structures in the AIL tissue might play a significant role with respect to functional purposes and pain perception.

METHODS

We subjected 6 AIL specimens to histologic examination to identify the neural structures that are a mandatory requirement as a source of anterior knee pain. Specifically, we performed three-dimensional immunohistochemical investigation of subtyping, orientation, and detailed characterization of neural structures within the AIL tissue.

RESULTS

Histologic and three-dimensional immunohistochemical examinations confirmed the presence of neural structures in all 6 AIL specimens. We identified myelinated and unmyelinated nerve fibers, as well as all types of mechanoreceptors.

CONCLUSIONS

Free nerve endings are a mandatory requirement for pain perception as a result of AIL violation during tibial nailing. Our verification of all different types of mechanoreceptors in the AIL tissue makes a role of the ligament in knee joint function and proprioception highly probable. Further investigations are necessary to clarify possible correlations between neural supply and function of the AIL. Violation of the ligament during operative procedures should be avoided, although the significance of the AIL is still debated.

Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing

BACKGROUND

Fractures of the tibial shaft are routinely managed with intramedullary nailing. An increasingly accepted technique is the suprapatellar extended leg method. The aim of this study was to investigate whether the suprapatellar tibial nailing technique offers shorter intraoperative fluoroscopy times and lower radiation doses when compared to the traditional infrapatellar technique.

STUDY DESIGN AND METHODS

Data from 200 consecutive intramedullary tibial nailing operations in our level 1 Major Trauma Centre were retrospectively collected from a prospective database (January 2014-December 2017). Only acute diaphyseal nailing procedures were included. The operations were performed by seven senior trauma consultants experienced in both suprapatellar and infrapatellar tibial nailing. The operations were divided into two groups: infrapatellar and suprapatellar. Intraoperative radiation time and dose data were collected.

RESULTS

A total of 90 cases were included and analysed. The majority of the patients were male (82%). 37 operations were infrapatellar and 53 were suprapatellar. Independent samples t-test revealed lower radiation time and dose for the suprapatellar group. The infrapatellar group had a mean radiation time of 129.7 ± 56.6 s versus 94.4 ± 47.9 s for the suprapatellar group. The infrapatellar group had a mean radiation dose (Dose Area Product) 53.6 ± 34.2 cGY cm² versus 38.2 ± 26.7 cGY cm² for the suprapatellar group. The difference in mean radiation time and mean radiation dose were both significant (p = 0.002 and p = 0.02 respectively).

CONCLUSIONS

Suprapatellar tibial nailing is an increasingly accepted technique in the management of tibial fractures. It is shown here that amongst surgeons experienced in both suprapatellar and infrapatellar nailing techniques, the suprapatellar approach trends towards lower use of intra-operative fluoroscopy as measured by time and dose and thus potentially lower radiation exposure to the operating surgeon, assistants and patient.

Anterior intermeniscal ligament: frequency in MRI studies and spatial relationship to the entry point for intramedullary tibial nailing related to the risk of iatrogenic violation

BACKGROUND

Anterior knee pain is the most common complication after intramedullary tibial nailing. Often, the cause is multifactorial and individually different. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible origin of postsurgical anterior knee pain. Both the importance and function of the AIL remain somewhat ambivalent, and even the figures quoted in the literature for its existence in the population vary drastically. Our aim was to verify the estimated frequency of the AIL in the literature by retrospectively analysing the data of MRI studies conducted at our hospital. In addition, we attempted to assess the potential risk of AIL violation during intramedullary tibial nailing, based on the spatial arrangement.

METHODS

Two independent examiners analysed the images generated in 351 MRI studies conducted at our hospital between June 2013 and May 2014. All cases who did not reveal any previous knee-joint injury or osteoarthritis of the knee were allocated to group I. All other cases were included in group II. To estimate the potential risk of AIL injury during the nailing procedure, the distance between the AIL and the theoretical entry point for intramedullary nailing was measured.

RESULTS

We identified the AIL on the images of nearly all patients (96.5%) in group I. In group II, the presence of the AIL was confirmed in only 51.4% of cases (p < 0.001). The average distance between the AIL and theoretical entry point for intramedullary tibial nailing was 10.1 mm (range 3.48-18.88 mm).

CONCLUSIONS

Because we were able to confirm the presence of the AIL in nearly all patients without a history of knee joint injuries or osteoarthrosis, we presume that the AIL may play a role in knee joint function. Violation of the AIL during intramedullary nailing appears likely due to the close position of the AIL in relation to the entry point for the inserted nail. As a result and due to its rich sensory innervation, a connection between AIL violation during tibial nailing and postoperative onset of anterior knee pain seems likely. To eliminate one risk factor of anterior knee pain development and in view of the unresolved issues of AIL function, violation of the ligament during any operative procedure should be avoided.

Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment

Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

Suprapatellar versus infrapatellar intramedullary nailing for treatment of tibial shaft fractures in adults

BACKGROUND

Numerous studies have compared suprapatellar (SP) nailing to infrapatellar (IP) nailing for treatment of tibial shaft fractures; however, the best strategy remains controversial. The aim of this meta-analysis is to assess whether SP or IP nailing is more effective for tibial shaft fractures in adults.

METHODS

Literature searches of PubMed, Embase, OVID, Cochrane Library, Web of Science, Chinese Biomedical Literature, Wanfang, Weipu Journal, and CNKI databases were performed up to July 2017. Only randomized controlled trials (RCTs) comparing SP versus IP intramedullary nailing for tibial shaft fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

RESULTS

Twelve RCTs were selected for analysis. SP intramedullary nailing reduced knee joint pain, visual analog score, fluoroscopy time, and sagittal angle, resulting in better Harris hip score, Lysholm knee score, short-form 36 questionnaire, range of motion, and rates of "excellent" and "good" outcome. There were no significant differences in operative time, blood loss, length of hospital stay, union time, and coronal angle between groups.

CONCLUSION

The present meta-analysis indicates that SP intramedullary nailing has obvious advantages over IP intramedullary nailing for treatment of tibial shaft fractures in adults. However, owing to the low-quality evidence currently available, additional high-quality RCTs are needed to confirm these findings.

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal

BACKGROUND

The removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication.

METHODS

This is a retrospective seven-year (2010-2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital's orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed.

RESULTS

A total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail's distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula.

CONCLUSION

Nail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.

Suprapatellar versus infrapatellar intramedullary nailing for tibal shaft fractures: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the outcome of using tibial nails inserted by the suprapatellar approach with tibial nails inserted by the infrapatellar approach in a meta-analysis of randomized controlled trials (RCTs).

METHODS

The following electronic databases were searched: PubMed (1966 to January 2018), EMBASE (1974 to January 2018), Cochrane Library (January 2018), Web of Science (1990 to January 2018). We also used Google Search Engine to search more potentially eligible studies until January 2018. The methodological qualities of included studies were assessed in accordance with the guidelines provided by the Cochrane Collaboration for Systematic Reviews. The statistical analysis all of included studies were performed by STATA 13.0 software. The outcomes were total blood loss, postoperative pain, range of motion (ROM), Lysholm knee score, fluoroscopy time, operation time, and postoperative complications.

RESULTS

Four RCTs published between 2015 and 2017 were selected in the meta-analysis. There was a significant difference between suprapatellar and infrapatellar approach surgery in total blood loss, postoperative pain, ROM, Lysholm knee scores, and fluoroscopy times.

CONCLUSIONS

The suprapatellar approach for intramedullary nailing appears superior to the infrapatellar approach, with a reduction in total blood loss, improved postoperative pain, shorter fluoroscopy time, and better knee functionality outcomes. There was no increased incidence of postoperative complications between the 2 groups. Further research remains necessary.