The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test – Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain.Aims
Patients and Methods
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.
