Surgical approaches to intramedullary nailing of the tibia: Comparative analysis of knee pain and functional outcomes |
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| Institution: | 1. University of Rochester Medical Center, Rochester, NY, United States;2. Washington Univ. School of Medicine, St. Louis, MO, United States;1. Department of Mechanical Engineering, University of Melbourne, Parkville, Victoria 3010, Australia;2. Department of Orthopaedic Surgery, Epworth Healthcare, Richmond, Victoria 3121, Australia;3. Centre for Limb Reconstruction, The Epworth Centre, Richmond, Victoria 3121, Australia;4. Department of Surgery, Southern Clinical School, Monash University, Clayton, Victoria 3168, Australia;1. Department of Trauma, Hand and Reconstructive Surgery, University Medical center Marburg, Baldingerstraße, 35043 Marburg, Germany;2. Institute for Medical Biometry and Epidemiology, Philipps-University, Marburg, Germany;3. Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany;1. Department of Orthopaedics and Trauma Surgery, University Hospital Freiburg, Germany;2. Department of Radiology, University Hospital Freiburg, Germany;3. Department of Radiology, Kreiskrankenhaus Emmendingen, Germany;1. Akdeniz University, School of Medicine, Department of Orthopaedics and Traumatology, Turkey;2. Samsun 19 May?s University, School of Medicine, Department of Orthopaedics and Traumatology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey;3. Antalya Training and Research Hospital, Department of Rheumatology, 07100 Antalya, Turkey;1. Department of Trauma & Orthopaedics, Morriston Hospital, College of Medicine, Swansea SA6 6NL, United Kingdom;2. Department of Trauma, Morriston Hospital, College of Medicine, Swansea SA6 6NL, United Kingdom;3. F1 Doctor, Wales, United Kingdom;4. Plastic Surgery SpR, Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, United Kingdom;5. Frenchay Hospital, Bristol, United Kingdom;6. Morriston Hospital, United Kingdom;7. Institute of Life Science, College of Medicine, Swansea University SA2 8PP, United Kingdom |
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| Abstract: | IntroductionPost-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches.MethodsA trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n = 34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p < 0.05.ResultsComparison of knee pain severity between the groups found no significant difference (p = 0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p = 0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p = 0.04). There was no significant difference in knee pain location (p = 0.45).ConclusionIn this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint. |
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| Keywords: | Tibial nail Intramedullary nail Knee pain Tibia Semiextended Medial parapatellar Patellar tendon split Lysholm knee scale Surgical approach |
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