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Thwaites S, Abrahams J, Thewlis D, Rickman M. 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. Eur J Trauma Emerg Surg 2024; 50:59-70. [PMID: 37555990 PMCID: PMC10924025 DOI: 10.1007/s00068-023-02338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/23/2023] [Indexed: 08/10/2023]
Abstract
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.
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Affiliation(s)
- Simon Thwaites
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
| | - John Abrahams
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark Rickman
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Pires RE, Bidolegui F, Xicará JA, Altamirano-Cruz MA, Carabelli GS, Valderrama-Molina CO, Gómez A, Velarde JE, Azi ML, Belangero WD, Giordano V. Is there a trend towards semi-extended knee positioning during intramedullary tibial nailing in Latin America? A survey among 990 orthopaedic surgeons. Injury 2023; 54 Suppl 6:110774. [PMID: 38143123 DOI: 10.1016/j.injury.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/24/2023] [Accepted: 05/01/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the Latin American orthopaedic trauma surgeons preference regarding knee positioning and entry portals for IM nailing and identify the reasons of these preferences. METHODS Using the AO Trauma database, 22.285 surveys were distributed by email to Latin American orthopaedic surgeons. Demographic data and practice patterns, especially regarding knee positioning and approach for tibial nailing, were then evaluated and statistically treated. RESULTS amongst one thousand five hundred fourteen responses, 990 orthopaedic surgeons (4.4% of response rate) fully responded to the survey. Transpatellar tendon approach (613 / 61.9%,) with the knee in flexion (518 / 52.3%) on a radiolucent table remains the standard practice for intramedullary tibial nailing. Even for proximal and distal tibial nailing, the transpatellar tendon approach (455 / 46%) with the knee in flexion (562 / 56.8%) hold on the most used method. Only 55 (9.36%) orthopaedic surgeons reported that they have migrated to the supra-patellar tibial nailing in the recent years. The main reasons for a low rate of migration were lack of knowledge about the technique and unavailability of specific gigs and cartilage protectors for a safe suprapatellar nailing. CONCLUSION Even with the potential benefits of the semi-extended knee positioning for tibial nailing, the Latin American orthopaedic community remains using the transpatellar tendon approach with the knee in flexion as the standard technique. Lack of surgical training for suprapatellar and parapatellar approaches with the knee in semi-extension, added by the unavailability of suprapatellar jigs and soft outer protection sleeves contribute to counter the trend towards the semi-extended techniques.
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Affiliation(s)
- Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil.
| | - Fernando Bidolegui
- Servicio de Ortopedia y Traumatología, Hospital Sirio Libanés, Buenos Aires (BA), Argentina
| | - José Arturo Xicará
- Servicio de Ortopedia y Traumatología, Universidad San Carlos, Quetzaltenango, Guatemala
| | | | | | | | - Amparo Gómez
- Hospital Universitario de la Samaritana, Colombia
| | | | | | | | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Professor Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro (RJ), Brazil
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Lee JW, Byun SE, Kim YW, Byun YS, Yoon YC, Sohn HS. Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance? Clin Orthop Surg 2023; 15:704-710. [PMID: 37811504 PMCID: PMC10551684 DOI: 10.4055/cios23036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 10/10/2023] Open
Abstract
Background Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. Methods In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. Results No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. Conclusions Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.
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Affiliation(s)
- Jin-Woo Lee
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong-Eun Byun
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young-Woo Kim
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Young-Soo Byun
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Yong-Cheol Yoon
- Department of Orthopaedic Surgery, Gachon University Gil Hospital, Incheon, Korea
| | - Hoon-Sang Sohn
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Graulich T, Gerhardy J, Omar Pacha T, Örgel M, Macke C, Krettek C, Omar M, Liodakis E. Patella baja after intramedullary nailing of tibial fractures, using an infrapatellar/transtendinous approach, predicts worse patient reported outcome. Eur J Trauma Emerg Surg 2021; 48:3669-3675. [PMID: 34727191 PMCID: PMC9532308 DOI: 10.1007/s00068-021-01807-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 10/07/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Tilman Graulich
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Julius Gerhardy
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Tarek Omar Pacha
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Marcus Örgel
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Christian Macke
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Mohamed Omar
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Emmanouil Liodakis
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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Fontalis A, Weil S, Williamson M, Houston J, Ads T, Trompeter A. A comparison of anterior knee pain, kneeling pain and functional outcomes in suprapatellar versus infrapatellar tibial nailing. Eur J Orthop Surg Traumatol 2021; 31:1143-1150. [PMID: 33417043 DOI: 10.1007/s00590-020-02851-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/15/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Anterior knee pain and kneeling pain are some of the most common complications following intramedullary nailing of tibial shaft fractures. With the increased uptake of suprapatellar nailing at our institution, we undertook a service evaluation to assess anterior knee pain and kneeling pain in patients who underwent the suprapatellar tibial nailing technique compared with the infrapatellar approach. METHODOLOGY Data from all consecutive intramedullary tibial nailing operations between January 2014 and July 2017 were analysed from a prospectively collected database. All acute diaphyseal fracture nailing procedures were included. All patients were reviewed between six-month and four-year post-operation. Each patient was asked to complete a standardised questionnaire with three main outcome measures: pain on kneeling, presence of anterior knee pain and the severity of pain. RESULTS After exclusions, a total of 148 patients were identified. A total of 102 responses were received, 41 in the infrapatellar group (73.2%) and 61 in the suprapatellar group (66.3%). A longer time from surgery to telephone follow-up response was noted in the infrapatellar group: 32.4 months (interquartile range, 16.1) vs. 19.3 months (interquartile range, 17.4), p < 0.001. A trend towards lower reported anterior knee pain was noted in the suprapatellar group (67.9% VS 53.7%). Most patients reported mild or no pain on kneeling, with no significant difference between the two groups. There was also no significant difference in severity of knee pain between the two groups and no significant effect on the Kujala score. CONCLUSION With the comparable pain outcomes between the two groups, our analysis supports the continued use of the suprapatellar tibial nailing technique for tibial shaft fractures at our institution.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Simon Weil
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Michael Williamson
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - James Houston
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Tamer Ads
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK.
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Valsamis EM, Iliopoulos E, Williams R, Trompeter A. Suprapatellar tibial nailing: a learning curve analysis. Eur J Trauma Emerg Surg 2019; 46:1107-1113. [PMID: 31256209 DOI: 10.1007/s00068-019-01177-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. METHODS Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. RESULTS Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. CONCLUSIONS Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.
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Affiliation(s)
- Epaminondas Markos Valsamis
- Trauma and Orthopaedics Department, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, UK.
| | - Efthymios Iliopoulos
- Trauma and Orthopaedics Department, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Rachel Williams
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Alex Trompeter
- Trauma and Orthopaedics Department, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
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Cazzato G, Saccomanno MF, Noia G, Masci G, Peruzzi M, Marinangeli M, Maccauro G. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series. Injury 2018; 49 Suppl 3:S61-S64. [PMID: 30415670 DOI: 10.1016/j.injury.2018.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 02/08/2023]
Abstract
Tibial shaft fractures are extremely common injuries. High rate of union, acceptable alignment in all planes, and a low complication rate have been reported when diaphyseal fractures are treated by intramedullary nailing. However, knee pain after tibial nailing has historically been problematic. While the exact aetiology of the knee pain is still unknown, surgical approach relative to the patellar tendon, nerve transection, violation of the fat pad or joint capsule as well as nail diameter and implant prominence have been claimed as possible causes. Therefore, establishing an appropriate starting point remains a crucial step in the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Literature is lacking on this topic, therefore the present article discusses clinical outcomes of 25 patients treated by suprapatellar nailing at 2 years follow up and a literature review.
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Affiliation(s)
- G Cazzato
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M F Saccomanno
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy.
| | - G Noia
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - G Masci
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M Peruzzi
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M Marinangeli
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - G Maccauro
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
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Franke J, Mueckner K, Alt V, Schnettler R, Franke AP, Griewing S, Hohendorff B. 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. Eur J Trauma Emerg Surg 2018; 46:1085-1092. [PMID: 30269211 DOI: 10.1007/s00068-018-1019-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 09/24/2018] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Joerg Franke
- Department of Trauma and Orthopaedic Surgery, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682, Stade, Germany.
| | - Kersten Mueckner
- Department of Radiology Clinic Dr. Hancken, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682, Stade, Germany
| | - Volker Alt
- Department of Trauma, Hand and Reconstructive Surgery, Justus-Liebig-University Giessen, Rudolf-Buchheim-Strasse 6, 35385, Giessen, Germany
| | - Reinhard Schnettler
- Justus-Liebig-University Giessen, Rudolf-Buchheim-Strasse 6, 35385, Giessen, Germany
| | - Anissa Paulina Franke
- Department of Trauma and Orthopaedic Surgery, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682, Stade, Germany
| | - Sebastian Griewing
- Justus-Liebig-University Giessen, Rudolf-Buchheim-Strasse 6, 35385, Giessen, Germany
| | - Bernd Hohendorff
- Department of Trauma and Orthopaedic Surgery, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682, Stade, Germany
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Hanson CG, Hanson LF. Non-invasive repair of an iatrogenic tibial artery branch pseudoaneurysm after intramedullary nailing. J Clin Orthop Trauma 2017; 8:S49-S51. [PMID: 29158648 PMCID: PMC5681231 DOI: 10.1016/j.jcot.2017.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022] Open
Abstract
Tibial fractures are a commonly seen injury in orthopedic surgery. Intramedullary nailing is considered the standard of care, as complications are rare. Those of a vascular nature, including iatrogenically induced pseudoaneurysms of the tibial artery have been previously described in the literature, however each reported case has required surgical repair. In the current case, we describe a repair of a tibial artery branch pseudoaneurysm, after direct contact with an interlocking screw from tibial intramedullary nailing, via ultrasound-guided thrombin injection. To the authors' knowledge, this is the first reported case of a tibial artery pseudoaneurysm repaired non-surgically. This adds support to the promising literature on non-invasive repair of orthopedically related pseudoaneurysms.
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Affiliation(s)
- Cameron G. Hanson
- College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO 64106, United States
| | - Logan F. Hanson
- Department of Orthopaedic Surgery, Beaumont Health, Farmington Hills, MI 48336, United States
- Department of Orthopaedics & Sports Medicine, Methodist Hospital & Physicians, Indiana University Health, Indianapolis, IN 46202, United States
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Greve F, Crönlein M, Beirer M, Kirchhoff C, Biberthaler P, Braun KF. Pseudoaneurysm of the anterior tibial artery after interlocking tibial nailing: an unexpected complication. Eur J Med Res 2016; 21:36. [PMID: 27687142 PMCID: PMC5043624 DOI: 10.1186/s40001-016-0231-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
Anterior tibial pseudoaneurysm is a rare complication after interlocking screw insertion in tibial nailing. We present the case of a 28-year-old male patient with this complication with a 6-week delay after tibial nailing of a right tibial fracture type 42-A1 of the Association for the Study of Internal Fixation (AO/ASIF) classification. On presentation to our emergency department, the patient's complaints were solemnly intermittent pain and occasional swelling of his proximal lower leg. Deep vein thrombosis, compartment syndrome, and implant dislocation were ruled out, and the patient was discharged after his symptoms improved without further intervention. Four weeks later, the patient was readmitted for similar symptoms. A computed tomography (CT) angiography then revealed a pseudoaneurysm of the anterior tibial artery at the level of the proximal interlocking screw insertion. Aneurysmal sac excision with vessel repair was performed while reconstructing the additional dislocated proximal fibular fracture using standard AO/ASIF plating. Postoperatively, sufficient flow through the repaired vessel was documented using Doppler ultrasound and CT angiography. However, the patient sustained a temporal damage to the peroneal nerve after surgery. This case highlights the risk of a pseudoaneurysm of the anterior tibial artery after interlocking screw insertion as a rare but major complication of a routine surgical procedure. Early ultrasound diagnostics, CT angiography, or magnetic resonance (MR) angiogram should be performed to prevent the delay in diagnosis and treatment of such complications.
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Affiliation(s)
- F Greve
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - M Crönlein
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - M Beirer
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - C Kirchhoff
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - P Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - K F Braun
- Klinik und Poliklinik für Unfallchirurgie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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Jankovic A, Korac Z, Bozic NB, Stedul I. Influence of knee flexion and atraumatic mobilisation of infrapatellar fat pad on incidence and severity of anterior knee pain after tibial nailing. Injury 2013; 44 Suppl 3:S33-9. [PMID: 24060016 DOI: 10.1016/s0020-1383(13)70195-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We evaluated the incidence and aetiology of anterior knee pain (AKP) in a series of patients that underwent intramedullary nailing for stabilisation of tibial fractures. During the preparation of the entry site no excision of the infrapatellar fat was allowed and electrical haemostasis was kept at the lowest level. Medullary canal was reamed and the nails inserted in position of knee flexion over 100 degrees. All fractures were fixed using medial paratendinous approach. Functional outcome was measured using Lysholm knee score. The knee range of movement and return to previous level of activity were also documented and analysed. Mean follow up was 38.9 months (range 12-84 months). In total 60 patients with 62 tibial shaft fractures were analysed. The mean age at the time of final follow up was 49.4 years (range 20-87). In 22 (35.5%) a newly developed and persisting pain in the anterior region of the operated knee was reported. According to VAP scale, the pain was mild (VAS 1-3) in 12 cases (19.4%) and moderate (VAS 4-6) in 10 (16.1%). In 16 cases (73%) the pain was noticed 6-12 months after injury and subjectively related to return to full range of working and recreational activities. The mean Lysholm knee score in the group without AKP was 90.8. In the AKP group with mild pain it was 88.4 and in the group with moderate AKP it was 79.9. Complete return to previous professional and recreational activities occurred in 49/60 patients (81.7%). Content with the treatment regarding expectations in recovery dynamics and return to desired level of activity was present in 98.3% of patients; one patient was unsatisfied with the treatment. Our results indicate that respecting the physiological motion of Hoffa pad and menisci during knee flexion, accompanied with atraumatic mobilisation of retrotendinous fat, reduces incidence and severity of anterior knee pain following intramedullary fixation of tibial shaft fractures.
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Affiliation(s)
- Andrija Jankovic
- Department of Traumatology, Division of Surgery, General Hospital Karlovac, Andrije Stampara 3, 47000 Karlovac, Croatia.
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