Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage

Abstract

Aim. Intramedullary nailing (IMN) is widely accepted as the treatment of choice for tibial fractures, and a suprapatellar method has been described to prevent common problems associated with the typical infrapatellar IMN technique, such as anterior knee pain. However, in the suprapatellar technique, injury to intra-articular structures is a concern. The aim of this study was to compare the clinical and radiological results of suprapatellar and infrapatellar IMN in terms of union, complications, and function. Methods. A retrospective evaluation of 61 patients who had undergone suprapatellar (n = 29, Group A) or infrapatellar (n = 31, Group B) tibial IMN was conducted. For the suprapatellar group, magnetic resonance imaging scans were acquired on the sixth month follow-up. Complications, radiological findings, functional outcomes, surgery duration, and differences in a range of motion (ROM) were compared. Results. Surgery duration was significantly shorter in Group A (81 mins vs. 107 mins, $p<0.001$ ), and visual analog scale (VAS) values were significantly higher in Group B (0.17 vs. 1.62, $p<0.001$ ). In Group A, the patients’ Lysholm scores were significantly higher (95.6 vs. 92, $p=0.006$ ). In terms of anterior knee pain, none was experienced in Group A (0%), while 11 patients (26.1%) reported about it in Group B. There were no statistically significant differences between the two groups in SF-36 score ( $p=0.925$ ), the radiographic union scale in tibial (RUST) fractures score ( $p=0.454$ ), union time ( $p=0.110$ ), or ROM ( $p=0.691$ ). In Group A, two cases of patellofemoral cartilage degeneration were observed. Conclusion. If performed with sufficient expertise, the suprapatellar IMN technique is a safe, reliable technique with a low frequency of anterior knee pain for treating tibial fractures. There is no clear evidence that it causes damage to intra-articular structures. The possibility of patellofemoral cartilage degeneration due to this technique should be further evaluated by prospective studies including pre- and postoperative radiologic assessments.