Influence of Nail Prominence and Insertion Point on Anterior Knee Pain After Tibial Intramedullary Nailing

Abstract

Chronic anterior knee pain is the most common complication after tibial nail insertion. Its etiology remains unknown, and multifactorial sources have been suggested. The authors believe that nail prominence and the insertion point of the nail are important in the development of anterior knee pain. The purpose of this retrospective study was to evaluate the roles of the insertion point and nail prominence in anterior knee pain after tibial intramedullary nailing using a transtendinous approach and a common nail type. A total of 108 patients with tibial shaft fractures underwent reamed intramedullary nailing using a transtendinous approach between 2006 and 2009. Mean follow-up was 26.8±5.0 months. A visual analog scale (0-100) was used to estimate anterior knee pain severity while patients performed 7 activities retrospectively. Radiographic assessments, including nail prominence and insertion point, were performed. Sixty (55.6%) patients experienced knee pain (group P) and 48 (44.4%) did not (group N). Significant differences were not found between the groups with respect to demographics, nail diameters, or fracture classifications. Less superior and more anterior nail prominences in radiographic assessments were significantly associated with anterior knee pain. When the insertion point was over the bottom half of the anterior cortex, the influence of anterior nail prominence was more obvious. Nail removal resulted in diminished pain during the 7 assessed activities. Nail insertion should be over the bottom half of the anterior cortex, with minimal anterior nail prominence. If anterior knee pain occurs, removal of the nail should be considered.

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

“…Etiologies may include iatrogenic damage to the IP nerve, 42 to Hoffa's fat pad, 44 periosteal irritation of the entry point, patellar tendinopathy, or nail prominence. 45 Moreover, knee pain persists after nail removal in up to 60% of the cases. 5 , 42 , 46 It may be noteworthy that the IP-approach is used for implant removal, even after initial SP-nailing.…”

Complications during removal of stainless steel versus titanium nails used for intramedullary nailing of diaphyseal fractures of the tibia

“…Boerger et al investigated the outcome of 100 nail removals, and reported that intramedullary nail removal is a safe procedure, but anterior knee pain may persist in a significant proportion of patients after nail removal [ 10 ]. There are few reports in the literature of the complications associated with the removal of intramedullary nails [ [9] , [10] , [11] , [12] ]. Depending on study design and composition and position of nails, nail removal may cause various problems and the operating time, amount of bleeding, and difficulty of removal can vary accordingly.…”

Influence of Nail Prominence and Insertion Point on Anterior Knee Pain After Tibial Intramedullary Nailing

“…1 They highlight the important conclusion that the cause of anterior knee pain following tibial intramedullary nailing remains unknown, with multifactorial sources having been reported.…”

“…1 The source of anterior knee pain following tibial intramedullary nailing remains unknown and is most likely multifactorial. 1,2 We believe that having 2 groups of patients with homogeneous characteristics minimizes the effects of multiple causes of anterior knee pain.…”

“…1 The source of anterior knee pain following tibial intramedullary nailing remains unknown and is most likely multifactorial. 1,2 We believe that having 2 groups of patients with homogeneous characteristics minimizes the effects of multiple causes of anterior knee pain. This methodology can be found in a study exploring the relationship between anterior knee pain occurring after tibial intramedullary nailing and the localization of the nail in the proximal tibia.…”