Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques

BACKGROUND: Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during nailing is thought to be a contributing cause of chronic anterior knee pain. The purpose of this prospective, randomized study was to assess whether the prevalence or the intensity of anterior knee pain following intramedullary nailing of a tibial shaft fracture is reduced by the use of a paratendinous incision for the nail entry portal. METHODS: Fifty patients with a tibial shaft fracture requiring intramedullary nailing were randomized equally to treatment with paratendinous or transtendinous nailing. Twenty-one patients from both study groups were followed for an average of three years after nailing. After fracture union, all but two patients had elective nail removal through the same surgical approach as was used for the nailing. At the follow-up evaluation, the patients used visual analog scales to report their level of anterior knee pain and the impairment caused by that pain. The scales described by Lysholm and Gillquist and by Tegner et al., the Iowa knee scoring system, and simple functional tests were used to quantitate the functional results. Isokinetic thigh-muscle strength was also measured. RESULTS: Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. CONCLUSION: Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.     

Anterior knee pain after intramedullary nailing of a tibial shaft fracture: an ultrasound study of the patellar tendons of 36 patients

OBJECTIVES: Chronic anterior knee pain is a common complication following intramedullary nailing of a tibial shaft fracture. The etiology of pain is often not known. This study sonographically examined the patellar tendons of patients with a nailed tibial shaft fracture. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Fifty consecutive patients with a nailed tibial shaft fracture were initially included in the study. Thirty-six of them could be measured at an average of 2.5 +/- 0.5 years after nail insertion (1.0 +/- 0.3 years after nail extraction). INTERVENTION: Reamed intramedullary nailing with 2 interlocking bolts at both ends of the nail (Grosse-Kempf-nail, Howmedica). MAIN OUTCOME MEASUREMENTS: The ultrasound investigation of the patellar tendons of the 36 patients. RESULTS: Twelve (33%) patients were painless and 24 (67%) patients had anterior knee pain at follow-up. With the reference to the mean difference in the thickness of the distal part of the patellar tendon in the operated limb versus nonoperated limb, the result was 1.4 +/- 1.1 mm in the chronic pain group and 2.6 +/- 2.5 mm in the painless group (P = 0.135, [95% confidence interval for the group difference = -0.4-2.8]). The corresponding values for the proximal part of the patellar tendon was 1.4 +/- 1.3 mm in the chronic pain group and 2.3 +/- 2.3 mm in the painless group (P = 0.251, [95% confidence interval for the group difference = -0.7-2.4]). There were no statistically significantly differences between study groups in the blood circulation of the patellar tendon or at the entry point, calcification of the patellar tendon, granulation tissue at the entry point, or occurrence of low echo areas in the patellar tendon. CONCLUSION: After intramedullary nailing of a tibial shaft fracture, patients with or without anterior knee pain show similar changes in the ultrasound investigation of their patellar tendons. Based on those findings, it does not appear to make any difference as to the approach used (paratendinous or transtendinous) for intramedullary nailing of the tibia.     

Anterior knee pain and thigh muscle strength after intramedullary nailing of a tibial shaft fracture: an 8-year follow-up of 28 consecutive cases

OBJECTIVES: Chronic anterior knee pain is a common complication after intramedullary nailing of a tibial shaft fracture. The source of pain is often not known, although it correlates with a simultaneous decrease in thigh muscle strength. No long-term follow-up study has assessed whether weakness of the thigh muscles is associated with anterior knee pain after the procedure in question. DESIGN: Prospective study. SETTING: University Hospital of Tampere, University of Tampere. PATIENTS: The muscular performance of 40 consecutive patients with a nailed tibial shaft fracture was tested isokinetically in a follow-up examination an average of 3.2 +/- 0.4 (SD) years after the initial surgery. An 8-year follow-up was possible in 28 of these cases. MAIN OUTCOME MEASUREMENTS: Isokinetic muscle strength measurements were made in 28 patients at an average 8.1 +/- 0.3 (SD) years after nail insertion and an average 6.6 +/- 0.3 (SD) years after nail extraction. All nails were extracted at an average 1.6 +/- 0.2 years after the nailing. RESULTS:: Seven patients were painless initially and still were at final follow-up (never pain, or NP). In 13 patients, the previous symptom of anterior knee pain was no longer present at final follow-up [pain, no pain (PNP)], and the remaining 8 had anterior knee pain initially and at final follow-up [always pain group (AP)]. With reference to the hamstring muscles, the mean peak torque difference between the injured and uninjured limb was -2.2% +/- 12% in the NP group, 1.6% +/- 15% in the PNP group, and 10.3% +/- 30% in the AP group at a speed of 60 degrees/second (Kruskal-Wallis test; chi(2) = 1.0; P = 0.593). At a speed of 180 degrees/second, the corresponding differences were -2.9% +/- 23% and 7.0% +/- 19% and 4.4% +/- 16% (Kruskal-Wallis test; chi = 1.7; P = 0.429). With reference to the quadriceps muscles, the mean peak torque difference was -2.8% +/- 9% in the NP group, 5.9% +/- 15% in the PNP group, and -13.0% +/- 16% in the AP group at a speed of 60 degrees/second (Kruskal-Wallis test; chi(2) = 7.9; P = 0.019). At 180 degrees/second, the corresponding differences were -9.4% +/- 13% and 4.9% +/- 16% and -1.9% +/- 9%, respectively (Kruskal-Wallis test; chi(2) = 4.8; P = 0.092). CONCLUSION: Based on this prospective long-term follow-up study, it appears that the anterior knee pain symptoms that are present after intramedullary nailing of a tibial shaft fracture disappear in a number of patients 3 to 8 years after surgery. Quadriceps, but not hamstring weakness, and lower functional knee scores are associated with anterior knee pain at 8 years.     

Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: a report of 40 consecutive cases

OBJECTIVES: Chronic anterior knee pain is a common complication following intramedullary nailing of a tibial shaft fracture. The source of pain is often not known nor is the reason for a simultaneous decrease in thigh muscle strength. Anterior knee pain has also been reported following an anterior cruciate ligament rupture. No previous investigation has assessed whether weakness of the thigh muscles is associated with anterior knee pain following intramedullary nailing of tibial shaft fractures. DESIGN: Prospective study. SETTING: University Hospital of Tampere, University of Tampere. PATIENTS: Fifty consecutive patients with a nailed tibial shaft fracture were initially included in the study. Ten patients did not have isokinetic strength testing for various reasons and were eliminated from the study. MAIN OUTCOME MEASUREMENTS: Isokinetic muscle strength measurements were done in 40 patients at an average 3.2 +/- 0.4 (SD) years after nail insertion (1.7 +/- 0.3 years after the nail extraction). RESULTS: Twelve (30%) patients were painless and 28 (70%) patients had anterior knee pain at follow-up. With reference to the hamstrings muscles, the mean peak torque deficit of the injured limb (as compared with the uninjured limb) was 2 +/- 11% in the painless group and 11 +/- 17% in the pain group at a speed of 60 degrees /s (P = 0.09, [95% CI for the group difference = -18% to 0%]). At a speed of 180 degrees /s, the corresponding deficits were -3 +/- 13% and 10 +/- 21% (P = 0.03, [95% CI for the group difference = -4% to -2%]). With reference to the quadriceps muscles, the mean peak torque deficit of the injured limb was 14 +/- 15% in the painless group and 15 +/- 15% in the pain group at speed of 60 degrees /s (P = 0.71, [95% CI for the group difference = -11% to 10%]). At a speed of 180 degrees /s, the corresponding deficits were 9 +/- 11% and 14 +/- 17% (P = 0.46, [95% CI for the group difference = -14% to 5%]). CONCLUSION: Based on this prospective study, we conclude that anterior knee pain after intramedullary nailing of a tibial shaft fracture, although of multifactorial origin, may be related to deficiency in the flexion strength of the thigh muscles.     

Anterior knee pain following intramedullary nailing of tibial shaft fractures: does bony portal point in the sagittal plane affect the outcome?

Forty-four consecutive diaphyseal extra-articular tibial fractures (43 patients) were treated with intramedullary interlocking nail. There were 35 men and eight women with a mean age of 38 years. Average follow-up was 25 months. Cases were divided into two groups: anterior-knee-pain group, 20 knees; and no-pain group, 24 knees. The lateral projection radiographs of their tibiae were scrutinised for precise bony portal point. The distance between articular surface and tibial tubercle was divided into three equal zones. In the superior zone, six had pain and six did not. In the central zone, eight had pain and 15 did not. In the inferior zone, six had pain and three did not. There was no significant difference between anterior knee pain and the three zones of the bony entry, age, gender, mechanism of injury, dynamisation, nail protrusion, approach and union time. We conclude that bony entry point in the sagittal plane is not a significant prognostic indicator for anterior knee pain following intramedullary tibial nailing.     

Altered knee kinematics in ACL-deficient non-copers: a comparison using dynamic MRI.

Kinematics measured during a short arc quadriceps knee extension exercise were compared in the knees of functionally unstable ACL-deficient patients, these patients' uninjured knees, and uninjured control subjects' knees. Cine phase contrast dynamic magnetic resonance imaging, in combination with a model-based tracking algorithm developed by the authors, was used to measure tibiofemoral kinematics as the subjects performed the active, supine posture knee extension exercise in the terminal 30 degrees of motion. Two determinants of tibiofemoral motion were measured: anterior/posterior location of the tibia relative to the femur, and axial rotation of the tibia relative to the femur. We hypothesized that more anterior tibial positioning, as well as differences in axial tibial rotation patterns, would be observed in ACL-deficient (ACL-D) knees when compared to uninjured knees. Multifactor ANOVA analyses were used to determine the dependence of the kinematic variables on (i) side (injured vs. uninjured, matched by subject in the control group), (ii) flexion angle measured at five-degree increments, and (iii) subject group (ACL-injured vs. control). Statistically significant anterior translation and external tibial rotation (screw home motion) accompanying knee extension were found. The ACL-D knees of the injured group exhibited significantly more anterior tibial positioning than the uninjured knees of these subjects (average difference over extension range=3.4+/-2.8 mm, p<0.01 at all angles compared), as well as the matched knees of the control subjects. There was a significant effect of interaction between side and subject group on A/P tibial position. We did not find significant differences in external tibial rotation associated with ACL deficiency. The changes to active joint kinematics documented in this entirely noninvasive study may contribute to cartilage degradation in ACL-D knees, and encourage more extensive investigations using similar methodology in the future.     

Late outcome of isolated tibial fractures treated by intramedullary nailing: the correlation between disease-specific and generic outcome measures

OBJECTIVES: To measure the late morbidity of nailed isolated tibial fractures, using both a generic health score and disease-specific scores. To determine the correlation between the two types of outcome measure. DESIGN: Retrospective study, using a combination of case notes and radiographic review plus current clinical assessment. SETTING: Fracture Outcomes Research Unit in a U.K. teaching hospital. PATIENTS: Eighty-three patients with isolated fractures of the tibial diaphysis. Follow-up time was a minimum of three years from injury (mean fifty-seven months). INTERVENTION: All patients were treated primarily by closed, reamed intramedullary nailing. OUTCOME MEASUREMENTS: Iowa Knee and Ankle Scores, visual analogue pain scores for fracture site and knee and ankle joints, and the Short Form 36 health status questionnaire. RESULTS: Sixty-four (77.1%) fractures united after the first procedure. Twenty-nine (34.9%) patients had pain around the knee at rest, fifty-nine (71.1%) had difficulty in kneeling, and thirteen (15.7%) were still experiencing some pain at their fracture site; 69% of patients had excellent results based on the Iowa scores as well as the SF-36 scores. Pain at the knee correlated with low Physical Component Summary and Mental Component Summary scores, and fracture site pain correlated with only low Physical Component Summary score. There was a significant correlation between the disease-specific scores and the SF-36 scores, and only patients with an excellent Iowa grade had "normal" SF-36 scores. CONCLUSION: After tibial nailing, mild deficits registered by Iowa scores are associated with a significant disability and unhappiness as registered by the SF-36. According to the patient-oriented outcomes tool, 31% of late results are "unsatisfactory."     

External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective,randomised study of 78 patients

Introduction We performed a prospective, randomised study to compare the Ex-fi-re external fixator (EF) with locked intramedullary (IM) nailing in tibial fractures. Only fractures without soft-tissue problems of importance were included.Materials and methods Ex-fi-re is a unilateral, dynamic axial fixator with fracture reduction capabilities. The Grosse-Kempf nail was used for nailing. A total of 78 patients with 79 fractures were entered in the study (41 Ex-fi-re, 38 IM nails).Results Time to radiographic union and full weight-bearing did not differ significantly, but unprotected weight-bearing was achieved earlier in the IM group (12 vs 20 weeks; p<0.001). There were more reoperations due to secondary dislocation in the EF group. There were no differences in final angulation or shortening. After 6 months and 1 year there were no differences in knee motion, ankle motion, fracture site pain or ankle pain. Some 64% of the nailed patients complained of anterior knee pain after 1 year.Conclusion The results were comparable in most respects. Unprotected weight-bearing was achieved earlier after IM nailing. Anterior knee pain was frequent after nailing.     

Patellar resurfacing in total knee arthroplasty. A prospective,randomized study

BACKGROUND: Anterior knee pain following total knee arthroplasty is a common complaint and typically is attributed to the patellofemoral joint. The purpose of the present study was to compare the outcome of resurfacing and nonresurfacing of the patella, particularly with regard to anterior knee pain, and to clarify the indications for patellar resurfacing at the time of total knee arthroplasty. METHODS: We performed a prospective, randomized study of 514 consecutive primary press-fit condylar total knee replacements. The patients were randomized to either resurfacing or retention of the patella. They were also randomized to either a cruciate-substituting or a cruciate-retaining prosthesis as part of a separate trial. The mean duration of follow-up was 5.3 years (range, two to 8.5 years), and the patients were assessed with use of the Knee Society rating, a clinical anterior knee pain score, and the British Orthopaedic Association patient-satisfaction score. The assessment was performed without the examiner knowing whether the patella had been resurfaced. At the time of follow-up, there were 474 knees. Thirty-five patients who had a bilateral knee replacement underwent resurfacing on one side only. RESULTS: The overall prevalence of anterior knee pain was 25.1% (fifty-eight of 231 knees) in the nonresurfacing group, compared with 5.3% (thirteen of 243 knees) in the resurfacing group (p < 0.0001). There was one case of component loosening. Ten of eleven patients who underwent secondary resurfacing had complete relief of anterior knee pain. The overall postoperative knee scores were lower in the nonresurfacing group, and the difference was significant among patients with osteoarthritis (p < 0.01). There was no significant difference between the resurfacing and nonresurfacing groups with regard to the postoperative function score. Patients who had a bilateral knee replacement were more likely to prefer the resurfaced side. CONCLUSIONS: As the present study showed a significantly higher rate of anterior knee pain following arthroplasty without patellar resurfacing, we recommend patellar resurfacing at the time of total knee replacement when technically possible.     

Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.

Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.     

胫骨干骨折髓内钉治疗术后膝关节痛的临床观察

目的通过对胫骨干骨折髓内钉内固定治疗后膝关节痛的临床观察,探讨膝关节痛的发生和病因。方法回顾研究1996年5月～2006年4月应用交锁髓内钉内固定治疗胫骨干骨折685例,所有病例在骨折愈合后均有1次以上的随访,平均随访时间为24.2个月。结果共有165例术后发生膝关节痛,经髌韧带入路组膝关节痛发生率为34.5%,髌韧带内侧入路组为14.6%,两组有显著性差异。结论髌韧带旁入路能减少胫骨干骨折髓内钉治疗术后膝关节痛的发生,建议使用髌韧带周围入路,髓内钉固定后膝关节痛的原因尚需进一步研究。     

开放楔胫骨高位截骨术对髌骨位置与关节功能的影响

目的：探讨开放楔胫骨高位截骨术对髌骨位置、膝前痛及关节功能的影响。方法：2016年6月至2021年6月,根据纳入和排除标准,共纳入采用开放楔胫骨高位截骨术治疗的膝关节内侧骨关节病患者109例（111膝）,其中男41例,女68例;年龄38～78(57.98±7.07)岁;病程1～36(8.58±6.91)个月。观察比较手术前后股胫角（femoral tibial angle,FTA）,胫骨近端内侧角（medial proximal tibial angle,MPTA）,负重位力线（weight bearing line,WBL）百分比,CD指数（Caton-Deschamps index）,髌骨外倾角（lateral patella tilt angle,LPTA）和髌骨外移（lateral patella shift,LPS）。采用Lysholm评分评价膝关节功能,视觉模拟评分（visual analogue scale,VAS）评价膝前痛程度,Kellgren-Lawrence (K-L)分级系统评价髌股关节骨关节炎进展情况。结果：109例患者获得随访,时间6～38(12.41±2....     

Injury to the infrapatellar branch of the saphenous nerve,a possible cause for anterior knee pain after tibial nailing?

The purpose of this study was to determine the long-term incidence of infrapatellar nerve damage after tibial nailing and its relation to anterior knee pain. We retrospectively evaluated 71 patients in whom 72 isolated tibial shaft fractures were treated with an intramedullary nail. The mean follow-up time was 84 months. Twenty-seven patients (38%) complained of chronic anterior knee pain. Infrapatellar nerve damage was found in 43 patients (60%). Of the 27 patients with knee pain, 21 (78%) had sensory deficits in the distribution area of the infrapatellar nerve, compared to 22 of the 45 patients (49%) without knee pain (p=0.025). Patient and fracture characteristics showed no significant differences between the two groups. At time of follow-up a total of 33 nails were removed of which twelve were taken out because of knee pain. The pain persisted in seven of these twelve patients (58%). The incidence of iatrogenic damage to the infrapatellar nerve after tibial nailing is high and lasting. Injury to this nerve appears to be associated with anterior knee pain after tibial nailing.     

Prospective comparison of retrograde and antegrade femoral intramedullary nailing

OBJECTIVE: To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures. DESIGN: Prospective, randomized. SETTING: Urban Level 1 trauma center. PATIENTS: One hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade. INTERVENTION: Ten-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming. OUTCOME MEASUREMENTS: A comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed. RESULTS: Knee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures. CONCLUSIONS: Both antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.     

Proximal entry for intramedullary nailing of the tibia. The risk of unrecognised articular damage

The risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been described. We have identified this complication in the treatment of tibial fractures, described the anatomical structures at risk and examined the most appropriate site of entry for tibial nailing in relation to the shape of the bone, the design of the nail and the surgical approach. We studied the relationship between the intra-articular structures of the knee and the entry point used for nailing in 54 tibiae from cadavers. The results showed that the safe zone in some bones is smaller than the size of standard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior part of the medial and lateral plateaux and the ligamentum transversum. This was confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibial nailing identified eight at risk according to the entry point and the size of the nail. Unrecognised articular penetration and damage during surgery were confirmed in four. Although intramedullary nailing has been shown to be a successful method for treating fractures of the tibia, one of the most common problems after bony union is pain in the knee. Unrecognised intra-articular injury of the knee may be one cause of this.     

髌上入路胫骨髓内钉治疗胫骨近端骨折

目的:探讨膝关节半伸直位髌上入路胫骨髓内钉治疗胫骨近端骨折的临床疗效。方法:2013年1月至2014年1月共收治胫骨近端骨折16例,男14例,女2例;年龄26～57岁,平均42.2岁。所有患者为单侧闭合骨折,采用膝关节半伸直位髌上入路META-NAIL胫骨髓内钉内固定治疗。记录手术时间、术后并发症、骨愈合时间、胫骨力线和膝关节活动范围,并采用视觉模拟评分法(visual analogue scale,VAS)和Lysholm膝关节评分评定手术疗效。结果:所有16例患者手术时间65～95 min,平均(75.7±8.3) min.无明显围手术期并发症发生。所有患者获随访,时间12～24个月,平均(15.6±8.1)个月。15例获得Ⅰ期骨愈合,平均骨愈合时间(3.6±1.8)个月(3～5个月).末次随访时,所有患者胫骨力线良好,无膝前疼痛。患侧膝关节屈伸活动范围平均(124.4±18.8)°,健侧(127.5±16.7)°。Lysholm膝关节评分77～92分,平均86.4±12.3.结论:膝关节半伸直位髌上入路胫骨髓内钉治疗胫骨近端骨折,术中复位及固定操作方便,术后并发症少,患肢功能恢复良好,临床疗效满意。     

胫骨干骨折髓内钉治疗后膝关节痛的临床研究

目的 通过对胫骨干骨折髓内钉内固定治疗后膝关节痛的临床观察，探讨膝关节痛的发生和病因。方法 回顾性研究我院1997年1月～2002年12月应用髓内钉内固定治疗胫骨干骨折的1332例病例。所有病例在骨折愈合后均有一次以上随访，平均随访时间为27个月。结果 共有409例胫骨干骨折术后发生患侧膝关节痛；经髌韧带入路组膝关节痛发生率为31.9％，髌韧带旁入路组为28.9％。结论 髌韧带旁入路不能减少胫骨干骨折髓内钉治疗术后膝关节痛的发生。     

Incision placement for intramedullary tibial nailing: an anatomic study

OBJECTIVES: For intramedullary nailing of tibial shaft fractures, a recent study has determined that the entry site should be just medial to the lateral tibial spine at the anterior margin of the articular surface. Gaining access to this site is often through a medial parapatellar or transpatellar approach. Several studies have indicated that a transpatellar approach may contribute to anterior knee pain. Our study sought to use anatomic measurement to determine the ideal incision site for insertion of an intramedullary tibial nail. DESIGN Part I: survey of Orthopaedic Trauma Association (OTA) members. Part II: anatomic study. SETTING: A Level I trauma center in Sacramento, California. PARTICIPANTS: Part I: OTA members. Part II: a group of 56 healthy volunteers. INTERVENTION: Part I: questionnaire sent to OTA members. Part II: clinical examination and radiographic analysis. MAIN OUTCOME MEASUREMENTS: Part I: responses to questionnaire. Part II: anatomic measurements. RESULTS: Part I: based on a questionnaire, OTA members use at least one or more approaches to access their preferred tibial nail entry site. Fifty-seven percent use only one type of approach in all cases. Part II: the authors performed a clinical and radiographic study in 56 volunteers (112 knees) to determine the relationship of the lateral tibial spine to the patellar tendon. On the basis of this information, the tendon was divided into thirds to account for the three most common surgical approaches. The entry site was in the lateral zone in 29 knees, the middle zone in 75 knees, and the medial zone in 8 knees. If divided equally into purely a medial or lateral zone to avoid a transpatellar approach, the starting point fell into the medial zone in 42 knees and the lateral zone in 70 knees. CONCLUSIONS: Individual variations in patellar tendon anatomy should be considered when choosing the proper entry site for tibial nailing. Based on the assumption that the ideal entry point for tibial nailing is just medial to the tibial spine at the anterior margin of the articular surface, a preoperative fluoroscopic measurement before incision can guide the surgeon as to whether a medial parapatellar, transpatellar, or lateral parapatellar approach provides the most direct access to this entry site. The routine use of a single approach for all tibial nails may no longer be justified.     

Selective patellar nonresurfacing in total knee arthroplasty. 10 year results.

Patella nonresurfacing in total knee arthroplasty was reviewed retrospectively in 49 knees (42 patients). Thirteen patients (17 knees) died leaving 29 patients (32 knees) in the final study group. The minimum length of followup was 10 years and averaged 11.7 years (range, 10-13.4 years). The diagnosis was primary osteoarthritis in 26 knees, posttraumatic arthritis in four, osteonecrosis in one, and Paget's disease in one. Patients were evaluated using the Knee Society score, a patella score, and radiographs. The mean Knee Society score improved from 52.8 to 87.5 points postoperatively and functional score improved from 57.5 to 84.5 points postoperatively. Anterior knee pain was reported in six knees (20%). Only one patient required secondary resurfacing of the patella because of postoperative anterior knee pain. No significant correlation was found between anterior knee pain and patellofemoral joint space, patellar sclerosis, Insall-Salvati ratio, patellar tilt, gender, obesity, or age. Based on the need for secondary patellar resurfacing because of anterior knee pain, the 10-year survival was 97.5%. At minimum 10-year followup, retaining the patella in total knee arthroplasty in selected patients with osteoarthritis of the osteoarthritic knee can yield acceptable results.