The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches.

95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort.

53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds.

We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach.

This ongoing prospective RCT compares two surgical approaches with respect to accuracy of guidewire and tibial nail position.

29 patients with tibial fractures were randomised to semi-extended (SE) or standard (S) approaches of tibial nail insertion. Fluoroscopy obtained guidewire and final nail position. The SE approach is more proximal with the guidewire inserted posterior to the patella, theoretically allowing more accurate wire and nail placement.

Measurements were taken in both planes of the nail and guidewire to determine deviation from optimum angle of insertion (relative to the long axes of the tibial shaft).

14 and 15 patients were treated with semi-extended and standard approaches respectively.

The semi-extended approach results in better guidewire and nail placement in both planes with mean deviation from the optimal angle of insertion as below:

Guidewire AP 4.5° (SE) versus 4.04° (S) Lateral 24.59° (SE) versus 33.36° (S)

Nail AP 3.21° (SE) versus 3.68° (S) Lateral 17.73° (SE) versus 24.04° (S)

Anterior knee pain may be due to excessive anterior placement of the nail. We assessed anterior placement of the guidewire and nail in the lateral plane. This was expressed as a percentage from the anterior cortex of the tibia. Mean results are below:

Guidewire 9.7% (SE) versus 9.3% (S)

Nail 19.5% (SE) versus 16.3% (S)

Semi-extended nailing may allow for better guidewire position and as such nail placement. This may reduce anterior knee pain.

Introduction: Although more than 30 different surgical procedures to achieve solid ankle fusion were described, after septic joint destruction or ongoing infection external fixation is preferred. In 1999 the referring institution reported on 45 cases with internal (screw) fixation and additional external fixation [1]. Later on we used hybrid external fixation including transfixation of the midfoot [2]. Since range of motion of the middle and forefoot is of great importance for limb function we designed a prospective study to compare fusion rate and limb function after ankle fusion without foot or midfoot transfixation.

Patients and Methods: Between 9/2000 and 2/2002 18 patients with septic ankle destruction were admitted for ankle fusion. 10 patients were treated with a fine wire ring fixator using 2 full rings in the tibia and one 5/8 shaped ring in the calcaneus and talus. Compression was applicated only between the distal tibia and the talus. Every 14 days the wires were retensioned. 8 patients were treated with a titanium compression nail in an antegrad technique. All operations were done by one surgeon. 14 patients had a posttraumatic osteitis complicated in 6 cases by polyneurophathy and in two cases previous fusion failed. 4 patients suffered from diabetic polyneuropathy, 2 of them with ongoing infection. In both techniques weight bearing was allowed after 3 weeks.

Results: External fixator was removed 16 weeks after operation on average (14w–18w). Solid fusion was achieved in 16 cases (88%). In 3 patients the fistula persisted in one of them fusion failed. Dynamic pedobarography showed better results in patients without fixation of the subtalar joint. (Compression nail)

Conclusion: The study showed similar fusion rates compared with surgical procedures including transfixation of the whole foot. Range of motion of the not fused joints of the foot was better because early physioptherapy was performed. The fixation of the fore and mid foot is not necessary to achieve solid fusion by increased stability.