Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

Labronici, Pedro José; Pires, Robinson Esteves Santos; Franco, José Sergio; Fernandes, Hélio Jorge Alvachian; Reis, Fernando Baldy dos

doi:10.1186/1754-9493-5-31

Cited by 18 publications

(14 citation statements)

References 25 publications

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“…13,15 Furthermore, unreamed procedures involving smaller-diameter nails are associated with a lower incidence of anterior knee pain, possibly because of less bone and soft tissue injury. 22 However, the current study failed to demonstrate a relationship between the incidence of anterior knee pain and sex, age, nail diameter, or fracture classification. The surgical approach used during IM nailing also contributes to anterior knee pain.…”

Section: Discussioncontrasting

confidence: 73%

“…24 Although the etiology of anterior knee pain remains unknown, it seems to be multifactorial. 9,[13][14][15][16][17][18][19][20][21][22] Keating et al 7 and Court-Brown et al 8 reported that younger patients tend to be more symptomatic than older patients, likely as a result of being more active. A few studies reported that women also tend to be affected more often than men.…”

Section: Discussionmentioning

confidence: 99%

“…13,14 In recent years, a growing number of studies have investigated the cause of anterior knee pain after tibial IM nailing. However, its etiology remains unknown, and multifactorial sources have been suggested, including surgical approach, 9,13 nail prominence, 14,15 thigh muscle strength, 16 insertion point with any accompanying iatrogenic intra-articular injury, 17,18 injury to the patellar tendon or Hoffa fat pad, 19,20 injury to the proximal tibiofibular joint, 21,22 and injury to the infrapatellar branch of the saphenous nerve. 23 However, limited studies have addressed the potential causal relationship of nail prominence and have usually included different approaches and/or nails in a single study.…”

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confidence: 99%

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

Chen¹,

Lin²,

Yang³

et al. 2014

Orthopedics

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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.

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Section: Discussioncontrasting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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

Chen¹,

Lin²,

Yang³

et al. 2014

Orthopedics

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“…In this approach, a medial longitudinal incision is made, with care being taken not to damage the patellar tendon or its sheath. The patellar tendon, the retropatellar fat pad and paratendinous tissue are retracted and, theoretically there would be no tissue injury [13]. Therefore, it was our belief that by this approach the patellar tendon would be protected from any additional trauma, as much as it is reasonably achievable.…”

Section: Discussionmentioning

confidence: 99%

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain

Daraboš

Banić

Lubina

et al. 2013

International Orthopaedics (SICOT)

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Purpose Anterior knee pain (AKP) is a common complication following intramedullary nailing of tibial shaft fractures. Our aim was, by analysing the postoperative lateral knee X-rays and clinical status (VAS score), to find the best intramedullary tip position of a non protruded nail that will provide the best postoperative outcome avoiding AKP. Methods We evaluated the postoperative outcome of 221 patients, from the last four years, with healed fractures initially treated with intramedullary reamed nails with two or three interlocking screws proximally and distally through a medial paratendinous incision for nail entry portal. Our aim was to analyse a possible relationship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tibial tuberosity (NT), measured postoperatively on lateral knee X-rays. Results Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): group A were patients with pain and group B without pain. The difference between the two groups concerning NP and NT measurements appeared to be statistically significant concerning NT measurement (p<0.05), with high accuracy according to the classification tree. Conclusions We presume that the position of the proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We conclude that the symptoms of AKP will not appear if the tip of the nail position is more than 5.5 mm from the tibial plateau (NP) and more than 2.5 mm from the tibial tuberosity (NT).

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“…Therefore, the distance from the tip of the nail to tibial plateau or the anterior border of the tibia was not the only factor contributing to knee pain. Labronici et al [12] performed CT scans on 30 patients treated with interlocking intramedullary nails who had complained of knee pain postoperatively, and the results showed that the proximal interlocking pin entered the tibiofibular joint in 20 of these patients, which may be the iatrogenic cause of knee pain. In addition, Hemigou and Cohen [13] have shown that postoperative knee pain correlated with damage to the internal structure of the knee joint, including the nerves and the fat pad under the patella.…”

Section: Discussionmentioning

confidence: 99%

Effects of intramedullary nail removal after tibial fracture repair: A prospective study

Mehraj¹,

Shah²

2018

Int. J. Orthop. Sci.

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Introduction: Tibial fractures are the most common long bone fracture. The standard of care for the treatment of diaphyseal tibial fractures is an intramedullary nail (IMN). Implant removal is one of the most common procedures in bone and joint surgery, and criteria for implant removal are typically left to the treating surgeon. We conducted a prospective study to investigate effects of intramedullary nail removal after tibial fracture union. Methods: Sixty patients at our hospital were enrolled in a prospective study and divided into moderate/severe knee pain (visual analog scale (VAS) -4) and mild/no knee pain (VAS < 4) groups after interlocking intramedullary nailing. Variables studied included the distance from the tip of the nail to the tibial plateau and the front of the tibia on a normalized lateral X-ray, the VAS score of knee and ankle pain, the range of motion of the knee and ankle, and Johner-Wruhs criteria before, 6 weeks after operation, and at the last follow-up. Results: Fifty-seven patients were followed for a mean of 8.4 (2-17) months. In patients with moderate or severe knee pain intramedullary nail removal led to significant pain reductions (p < 0.05). A significantly shorter distance from the tip of the nail to the tibial plateau (<10 mm) and the anterior border of tibia (<6 mm) was found in the 24 patients with moderate or severe knee pain. Conclusion: For patients complaining knee pain after interlocking intramedullary nailing of tibial fractures, especially with a short distance from the tip of the nail tail to the tibial plateau(<10 mm) and the anterior border of the tibia (<6 mm) removal of the intramedullary nails relieved the pain significantly.

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Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

Cited by 18 publications

References 25 publications

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

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

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain

Effects of intramedullary nail removal after tibial fracture repair: A prospective study

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