Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia

Abstract

Objective: To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury. Design: Retrospective cohort study. Setting: Academic Level I trauma center. Patients/Participants: All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours. Intervention: Intramedullary nailing of a tibia fracture with either the SP or IP approach. Main Outcome Measurements: Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful. Results: The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5–7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: −0.06, 95% confidence interval, −1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45). Conclusions: In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis

“…Interestingly, a recent meta-analysis by Wang positioning whilst the knee was in a semi-flexed position [11]. Our meta-analysis does, however, include more, recently published high-quality studies [18,[20][21][22][23][24]. This data, when pooled, clearly show no difference in fluoroscopy time.…”

“…Authors have hypothesised that post-operative knee pain is due to patellar tendon splitting, proximal nail protrusion, intra-articular structural damage and involvement of the infrapatellar nerve; the suprapatellar approach aims to avoid this [6,10]. However, it is difficult to conclude superiority of suprapatellar approach in terms of less post-operative pain as only 3 out of 12 studies used similar pain scoring systems [7,15,18]. Few other studies did mention about knee pain, but, unfortunately, they could not be included in our analysis due to insufficient reported data [17,21,23].…”

“…5). Pain scores were reported in 3 studies (n = 177) with a moderate level of heterogeneity (I 2 = 48%) [7,15,18]. The comparative analysis suggests that suprapatellar group had better pain scores when compared to the infrapatellar group (Fig.…”

“…the Hospital for Special Knee Surgery Score (HSS) in 2 studies [17,20], Kujala Knee Score in 2 studies [19,23] and Oxford Knee Score (OKS) in one study [16]. Pain scores assessed by Sun [7,15,18]. Even though NRS pain score is moderately higher than the VAS score, both are highly correlated pain scores [26].…”

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

“… 23 , 26 , 27 However, other studies found no differences in anterior knee pain and functional outcomes if compared to IP-nailing. 10 , 12 , 28 Furthermore, data on theoretical concerns regarding retropatellar chondropathy and infection rates after the SP versus IP-approach are scarce. The most recent systematic review on this subject was published in 2019 in this Journal 20 and concluded that the SP-approach results in less pain and better functional outcomes if compared with IP-approach.…”