International Journal of Orthopaedics Sciences 2024; 10(2): 183-190

E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2024; 10(2): 183-190 Functional and radiological outcomes of suprapatellar
© 2024 IJOS
www.orthopaper.com intramedullary nailing for tibia diaphyseal fracture-an
Received: 06-03-2024
Accepted: 08-04-2024 observational study
Dr. Velmurugan S
Consultant Orthopaedic Trauma, Dr. Velmurugan S, Dr. Kumar VSV, Dr. Anees M and Hemapriya AS
Foot & Ankle Surgeon, Asian
Orthopaedic Institute
(AOI), SRM Institutes for DOI: https://doi.org/10.22271/ortho.2024.v10.i2c.3551
Medical Sciences, Chennai,
Tamil Nadu, India Abstract
Background: For tibial shaft fractures, intramedullary nailing (IMN) is considered the preferred
Dr. Kumar VSV treatment because it has a high fracture union rate, allows early mobilization, reduces complications such
Consultant Orthopaedic Trauma, as infection, malunion, non-union or implant failure, and provides early stabilization, which decreases
Deformity Correction Surgeon, morbidity and mortality.
Asian Orthopaedic Institute Methods: The purpose of this study is to evaluate the functional and radiological outcomes of tibia
(AOI) SRM Institutes for diaphyseal fractures treated with intramedullary nailing through a suprapatellar approach from 2019 to
Medical Science, Chennai,
2021. Lower Extremity Functional Score (LEFS) was used to measure subjective functional outcomes,
Tamil Nadu, India
and knee range of motion (ROM) was used to measure objective functional outcomes, Radiological
Dr. Anees M
outcome was determined by the time of union of the fracture, pain scores were assessed by visual
Postgraduate Scholar, DNB analogue scale (VAS) and fluoroscopy time, blood loss and complications were recorded.
(Ortho), Asian Orthopaedic Results: Among 33 cases, all fractures healed completely without any secondary procedures. No patient
Institute (AOI) SRM Institutes had malunion, nonunion, or implant failure. The mean LEFS and knee ROM score at the end of 6 months
for Medical Science, Chennai, was 66.27±6.00, and 125.15±7.95 degrees for the affected extremity, the average time of union of
Tamil Nadu, India fracture was 13.58±1.86 weeks. Average blood loss during surgery was 82.58±12.06 ml and the average
radiation time was 84.18±6.77 seconds. 1 (3%) patient had anterior knee pain. Outcomes based on
Hemapriya AS observations are Excellent in 33.3%, good in 48.5%, fair in 18.2%, and Poor in 0%.
Master of Public Health, Conclusion: A tibia diaphyseal fracture treated by IMN through SP leads to better subjective functional
Independent Researcher, outcomes and excellent objective functional outcomes like knee ROM after 6 months.
Chennai, Tamil Nadu, India
Keywords: Tibia-diaphyseal fractures, intramedullary nailing, LEFS, Knee ROM

Introduction
The tibia shaft fracture is one of the most common long bone fractures and a common
consequence of high energy trauma with 2% of all fractures in adults [1-3]. Due to the increase
in the number of vehicles in India, complex trauma cases caused by road traffic accidents
(RTA) have increased progressively. In orthopaedic practice, the tibia is the most commonly
fractured bone due to its subcutaneous location. Open fractures are more common because one
third of its surface is subcutaneous throughout most of its length and the blood supply to the
tibia is more precarious than that of bones enclosed by heavy muscles. Due to the presence of
hinge joints in the knee and ankle, there is no adjustment for rotatory deformities after
fractures. Delayed union, non-union, and infection are the common complications, especially
after open fractures of the shaft of the tibia. So special care and expertise are required to treat
such fractures.
Several treatment methods are present for tibial shaft fractures, such as open reduction and
internal fixation with plates, external fixation, and intramedullary nailing (IMN) [4]. The IMN
has been proven to be reliable and efficient in the treatment of tibia shaft fractures with
increasing application [5]. Today IMN is the preferred choice of treatment for tibia shaft
fracture due to its superior advantages with fewer complications and re-operation [6-8].
Corresponding Author: However, IMN insertion through the infrapatellar (IP) approach is technically challenging due
Hemapriya AS to proximal fracture fragment displacement with knee flexion induced by quadriceps and
Master of Public Health,
Independent Researcher, extensor complex as well as the multiple adjustment made during imaging [9].
Chennai, Tamil Nadu, India
~ 183 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

Besides anterior knee pain was a common and perhaps the nephew-trigen meta nail that was inserted using appropriate
most frequent complication after IMN insertion through the IP instruments used in accordance with the manufacturer’s
approach, with the reported incidence varying from 10-80% operative technique.
[10, 11]
. The SP approach was developed as an alternative to Data was entered in MS Excel and analyzed in SPSS version
avoid these potential drawbacks. By splitting the quadriceps 21.0. Descriptive statistics were carried out by frequency and
tendon, the SP pouch and retro-patellar space can be accessed proportion for categorical variables and mean and standard
through an incision 2.5 cm from the patella. A cannula system deviation for quantitative variables. To check the association
is then used for the standard insertion of the tibia nail. The between the variables chi-square test and Fischer exact test
full or near full extension position of the leg assists in were used P-Value.
neutralizing the deforming forces of the quadriceps muscle
and 4 helps to maintain proper alignment of the proximal Procedure
tibia, it also helps to align comminute shaft fractures or highly  The patient is positioned supine on a radiolucent table,
unstable distal third fractures, cases in which maintaining and the injured leg is positioned with a roll under the
reduction against gravity in the flexed or hyper-flexed knee joint so that it is flexed to 20 degrees (Fig.1).
position can be extremely difficult. Also, the extended  A 4 cm to 5 cm longitudinal incision was made 2 cm
position of the lower limb allows for easier fluoroscopic superior to the patella. The quadriceps tendon was then
imaging [12]. The potential drawback of this approach is the split in line with the incision.
chance of articular injury. Therefore this prospective study  Entry points were just medial to the lateral tibial spine
aims to evaluate the functional and radiological outcomes of  Custom-made trocar and protective sleeve were inserted
tibial shaft fractures using Intramedullary Nailing through  A ball tip guide wire was then passed into the tibia, and
Suprapatellar approach. Measurement of the appropriate length of nail was
obtained.
Objectives  Serial reaming was done and the appropriate size of the
 To assess the Functional outcome using Lower Extremity nail was placed.
Functional Score and knee range of motion and  Usual Fracture reduction was done and confirmed by
radiological outcome by fracture union in radiograph fluoroscopy.
 To assess post-operative knee pain by visual analogue  A Proximal screw with custom-made proximal jig was
scale inserted.
 To find out Complications like anterior knee pain, non-  Then the distal screw was inserted by free hand technique
union, and surgical site infection under fluoroscopy (Fig 2).
 To calculate average blood loss & radiation time during  Wounds were irrigated and closed in a layered fashion
the procedure and covered by sterile dressings.

Methods Results
This was a facility-based prospective study conducted in the A total of 33 patients were included in the study. Table 1
Asian Joint Reconstruction Institute at SIMS hospitals, the shows the demographic characteristics of the patients. The
protocol of which was approved by the Institutional Ethical mean age of the Study participants was 42.8±19.5. The
Committee of the medical college and is consistent with all Majority of the patients were Males 27 (81.8%) and the
the ethical standards. All patients provided written informed remaining were females 6 (18.2%). among 33 patients, 9
consent. All skeletally mature patients with tibia diaphyseal (27.3%) had comorbidities and among the 9 patients 7
fractures (Open and closed fractures) undergoing (21.2%) had hypertension, 6 (18.2%) had Diabetes and 1 (3%)
suprapatellar intramedullary nailing and who were fit for had coronary artery disease. Road traffic accidents 31 (93.9%)
surgery medically were included in the study using were the most common mode of injury among the patients
consecutive sampling techniques from September 2019 to followed by domestic falls 2 (6.1%). The most common type
December 2021. Patients with prior fractures to the same of injury among the patients was closed fracture 22 (66.7%)
bone, pathological fractures, polytrauma, fatigue fracture, and and then compound fracture 11 (33.2%). The most common
patients with multiple fractures were excluded from the study. type of fracture was Transverse 12 (36.4%), followed by
All patients were discharged on 2nd post-operative day and wedge fracture 9 (27.3%). The most common fracture level
received the same antibiotics and analgesics and the same was middle 13 (39.4%), followed by distal level 7 (21.1%).
post-operative protocol. Post-operative physiotherapy The left side of the leg 20 (61%) was the most common side
initiated as soon as possible-ankle range of motion, static followed by the right of the leg 13 (39%).
quadriceps strengthening exercise, and active assisted knee Table 2 shows, the mean blood loss of the patients during the
range of motion. Weight bearing walking with a walker as surgery. The mean blood loss was 82.58 ml±12.06.
tolerated for all patients. Suture removal was done on 14th Table 3 shows the Mean LEFS Score of the patients. The
day. Patients were followed at 2 weeks, 6 weeks, 3 months, mean LEFS score after 6 weeks of surgery was 25.85±4.27,
and 6 months after surgery. Functional outcome and pain after 3 months was 49.27±5.63, and after 6 months was
score assessed. AP and lateral X-ray films were taken at 66.27±6.00.
follow-up for evaluation of the fracture healing, implant Table 4 shows the distribution of patients according to LEFS
position, and the general condition of the fracture site. Pain score, where all 33 (100%) patients had poor LEFS scores at 6
assessment was done by visual analogue scale, Subjective weeks post-surgery. After 6 months 11 (33.3%) had excellent
assessment of Functional outcome with lower extremity LEFS scores, 16 (48.5%) had good scores and 6 (18.2%)
functional score, and objective assessment with clinical patients had fair LEFS scores. (Fig.3 shows functional
evaluation for ipsilateral knee ROM. outcomes at 6 months).
All procedures were performed by a single senior orthopaedic Table 5, shows the association between LEFS score at 6
trauma surgeon. All patients in the study received SMITH and months after surgery and its influencing factors. Patients aged
~ 184 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

< 20 years and between 21-30 years had excellent scores after 6 months of 125.15 +/-7.95 degrees which when compared to
6 months of surgery. Lesser the age, the patients had an other studies, Sun et al. (13) (130.7±4.09) and Serbest et al.
[14]
excellent LEFS score compared to elderly people. There was (130.3±6.31).
a significant relationship between age and LEFS score after 6 The average time of radiological union was 13.58 weeks±1.86
months (p<0.05). Males had Excellent (90.9%) scores weeks. In this study, the mean union of time was 95 days, but
compared to females (9.1%). Gender, type of injury, type of in studies of Yang et al. [32], Wang et al. [35], and Huang et al.
[15]
fracture, and fracture level had no significant relationship , Liu et al. [16], Yan et al. [17], Fu SP et al. [18], it was 105.8,
with LEFS score at 6 months (p>0.05). 82.3, 100, 82.63, and 95.6 respectively.
Table 6 shows, the visual analogue scale of patients after In this study the incidence of anterior knee pain was in 1
surgery. The mean VAS score of patients after 2 weeks of patient out of 33 patients, which is relatively less and
surgery was 6.67±0.69, 4.52±0.62 after 6 months, 2.03±0.85 comparable with other studies, Huang et al. [15], Liu et al. [16],
after 3 months, and 0.55±0.71 at 6 months. Yan et al. [17], Wang et al. [19]. Anterior knee pain is the most
Table 7 shows the Knee ROM of the patients. The mean Knee common complication of the infrapatellar approach for tibia
ROM score after 2 weeks of surgery was 90±7.60, intramedullary nailing. The etiology remains unclear but it is
103.48±7.23 at 6 weeks, 114.24±7.61 at 3 months and most consistent with injury to the intraarticular knee
125.15±7.95 at 6 months. structures, longitudinal incision of the patellar tendon during
Table 8 shows the Knee ROM of the patients. The Knee ROM the transtendinous approach, and injury to the infrapatellar
after 2 weeks of surgery was < 90 degree for 21 (63.6%) nerve [20, 21]. By making the incision proximal to the patella,
patients and 91-100 degree for 12 (36.4%) patients. After 6 the suprapatellar approach avoids these potential causes of
weeks, the knee ROM was < 90 degrees for 3 (9.1%) of the anterior knee pain. Couterney et al. [22] reported that the
patients and between 91-100 degrees for 12 (36.4%) of the infrapatellar nerve is well protected in the suprapatellar
patients and 101-110 degrees for 19 (54.5%) patients. The approach, but cannot make any significant difference in the
knee ROM after 3 months of surgery was 3 (9.1%) patients incidence of pain between the supra and infrapatellar
had ROM between 91-100 degrees and 9 (27.3%) had ROM approaches.
between 101-110 degrees, 18 (54.5%) patients had ROM This study showed a reduced mean VAS score of 0.55±0.71 at
between 111-120 degrees and 3 (9.1%) patients had ROM 6 months which is comparable to other studies of Serbest et
more 120 degrees. al. [14] 1.12±1.5, and Sun et al. [13] 0.45±0.502. Daniel S [12]
Table 9 shows, the association between knee ROM at 6 demonstrated that the VAS score in the suprapatellar group
months after surgery and its influencing factors. There was a was equivalent to the infrapatellar group. Relived [23] reported
significant relationship between age, gender, type of fracture, that 38% of patients who underwent infrapatellar incisions
and fracture level knee ROM after 6 months (p < 0.05). had complications of chronic knee pain and the incidence of
Table 10 shows, the mean weeks of union of bones after knee pain was much higher than the rate in the suprapatellar
surgery. The mean time of union was 13.58±1.86. (Fig.4 group in our study, which was thought to be significantly
shows the pre and post-operative x-ray at 6 months) related to iatrogenic damage to the infrapatellar nerve.
Table 11 shows, the distribution of patients according to Gaines’s (24) study indicated that the overall incidence of
complications after surgery. 3% of the patients had Anterior articular structure injury was higher with the infrapatellar
Knee pain on exertion after surgery. The remaining 97% of approach than the suprapatellar approach through the
patients had no complications post-surgery. cadaveric study, but no statistical difference was observed.
Those potential causes of pain were theoretically avoided with
Discussion the suprapatellar approach, which might interpret the lower
The suprapatellar approach simplifies nailing proximal and VAS pain score in the suprapatellar group.
distal tibial fractures. In the present study, the functional The mean blood loss was 82.58 ml±12.06, which is lower
outcome didn’t show any difference based on the gender of when compared to Liu et al. [16] (92.7±8.8), and higher when
the patient, but age showed a statistically significant relation compared to Huang et al. [15] (70±5.2), and Fu SP et al. [18]
with functional outcome. The younger the patient better the (42.6±7.2). The mean Fluoroscopy time for the procedure was
functional outcome. Various factors influence the 84.18 seconds±6.77, which is of a little higher exposure
postoperative knee ROM, including damage to vascularity duration when compared to Courtney et al. [22] (80.8) and Sun
and soft tissue. This study showed a lower mean knee ROM at et al. [13] (80.61).

Table 1: Demographic characteristics of patients

S. No Variables Categories Frequency Percentage
˂20 4 12.1
21-30 8 24.2
31-40 5 15.2
1 Age 41-50 4 12.1
51-60 3 9.1
˃60 9 27.3
Total 33 100
Male 27 81.8
2 Gender Female 6 18.2
Total 33 100
Yes 9 27.3
3 Co-morbidities No 24 72.7
Total 33 100
Hypertension 7 21.2
4 Type of Co-morbidity*
Diabetes 6 18.2
~ 185 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

Coronary Artery Disease 1 3

Total 14 42.4
Road traffic accidents 31 93.9
5 Mode of injury Domestic fall 2 6.1
Total 33 100
Compound 11 33.2
6 Type of injury Closed 22 66.7
Total 33 100
Oblique 5 15.2
Segmental 3 9.1
Spiral 4 12.1
7 Type of Fracture
Transverse 12 36.4
Wedge 9 27.3
Total 33 100
Proximal 4 12.1
Proximal Middle 1 3
Middle 13 39.4
8 Fracture Level Middle Distal 5 15.2
Distal 7 21.2
Proximal Middle + Middle Distal 3 9.1
Total 33 100
Right 13 39.4
9 Side Left 20 60.6
Total 33 100

Table 2: Mean Blood loss and intra-operative Fluoroscopy Time

S. No Variables Mean± SD
1 Blood Loss 82.58±12.06
2 Fluoroscopy 84.18±6.77

Table 3: Mean LEFS Score of the patients

S. No Variables Mean ± SD
1 LEFS Score (6 weeks) 25.85±4.27
2 LEFS Score (3 months) 49.27±5.63
3 LEFS Score (6 months) 66.27±6.00

Table 4: Distribution of patients according to LEFS

LEFS Score
S. No Variables
Excellent Good Fair Poor
1 LEFS Score at 6 weeks 0 (0) 0 (0) 0 (0) 33 (100)
2 LEFS Score at 3 months 0 (0) 2 (6.1) 29 (87.9) 2 (6.1)
3 LEFS Score at 6 months 11 (33.3) 16 (48.5) 6 (18.2) 0 (0)

Table 5: Association between LEFS score at 6 months and its influencing factors
LEFS Score at 6 months
S. No Variables P-Value
Excellent Good Fair
Age
< 20 3 (27.3) 1 (6.3) 0 (0)
21-30 6 (54.5) 2 (12.5) 0 (0)
1 31-40 2 (18.2) 3 (18.8) 0 (0)
0.001
41-50 0 (0) 4 (25) 0 (0)
51-60 0 (0) 3 (18.8) 0 (0)
>60 0 (0) 3 (18.8) 6 (100)
Gender
2 Male 10 (90.9) 14 (87.5) 3 (50)
0.08
Female 1 (9.1) 2 (12.5) 3 (50)
Type of Injury
3 Compound 5 (45.5) 4 (25) 2 (33.3)
0.541
Closed 6 (54.5) 12 (75) 4 (66.7)
Type of Fracture
Oblique 2 (18.2) 2 (12.5) 1 (16.7)
Segmental 1 (9.1) 0 (0) 2 (33.3)
4
Spiral 0 (0) 4 (25) 0 (0) 0.142
Transverse 4 (36.4) 5 (31.3) 3 (50)
Wedge 4 (36.4) 5 (31.3) 0 (0)
Fracture Level
5
Proximal 1 (9.1) 2 (12.5) 1 (16.7) 0.532
~ 186 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

Proximal Middle 0 (0) 1 (6.3) 0 (0)

Middle 4(36.4) 7 (43.8) 2 (33.3)
Middle distal 3 (27.3) 2 (12.5) 0 (0)
Distal 2 (18.2) 4 (25) 1 (16.7)
Proximal middle + Middle distal 1 (9.1) 0 (0) 2 (33.3)

Table 6: Visual Analogue Scale during follow up

S. No Variables Mean + SD
1 VAS Score (2 weeks) 6.67±0.69
2 VAS Score (6 months) 4.52±0.62
3 VAS Score (3 months) 2.03±0.85
4 VAS Score (6 months) 0.55±0.71

Table 7: Mean Knee ROM during follow up

S.no Variables Mean + SD
1 Knee ROM Score (2 weeks) 90±7.60
2 Knee ROM Score (6 weeks) 103.48±7.23
3 Knee ROM Score (3 months) 114.24±7.61
4 Knee ROM Score (6 months) 125.15±7.95

Table 8: Distribution of Patients according to the Knee Range of Motion

Knee Rom
S. No Variables
< 90 91-100 101-110 111-120 >120
1 KNEE ROM at 2 weeks 21 (63.6) 12 (36.4) 0 (0) 0 (0) 0 (0)
2 KNEE ROM at 6 weeks 3 (9.1) 12 (36.4) 18 (54.5) 0 (0) 0 (0)
3 KNEE ROM at 3 months 0 (0) 3 (9.1) 9 (27.3) 18 (54.5) 3 (9.1)
4 KNEE ROM at 6 months 0 (0) 0 (0) 3 (9.1) 6 (18.2) 24 (72.7)

Table 9: Association between Knee ROM at 6 months & its influencing factors
KNEE ROM at 6 months
S. No Variables P-Value
101-110 111-120 >120
Age
< 20 0 (0) 0 (0) 4 (16.7)
21-30 0 (0) 0 (0) 8 (33.3)
1 31-40 0 (0) 0 (0) 5 (20.8)
< 0.005
41-50 0 (0) 1 (16.7) 3 (12.5)
51-60 0 (0) 0 (0) 3 (12.5)
>60 3 (100) 5 (83.3) 1 (4.2)
Gender
2 Male 2 (66.7) 3 (50) 22 (91.7)
0.04
Female 1 (33.3) 3 (50) 2 (8.3)
Type of Fracture
Oblique 1 (33.3) 1 (16.7) 3 (12.5)
Segmental 2 (66.7) 0 (0) 1 (4.2)
4
Spiral 0 (0) 0 (0) 4 (16.7) 0.01
Transverse 0 (0) 4 (66.7) 8 (33.3)
Wedge 0 (0) 1 (16.7) 8 (33.3)
Fracture Level
Proximal 0 (0) 1 (16.7) 3 (12.5)
Proximal Middle 1 (33.3) 0 (0) 0 (0)
5 Middle 0 (0) 3 (59) 10 (41.7)
0.05
Middle distal 0 (0) 1 (16.7) 4 (16.7)
Distal 0 (0) 1 (16.7) 6 (25)
Proximal middle + Middle distal 2 (66.7) 0 (0) 1 (4.2)

Table 10: Mean weeks of radiological union of fracture

S. No Variables Mean ±SD
1 Time of Union 13.58±1.86

Table 11: Distribution of Patients according to complication

S. No Variables Frequency Percentage
1 Anterior Knee pain on exertion 3 9.09
2 No complications 30 90.9
Total 33 100

~ 187 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

Fig 1: Positioning of Patient

Fig 2: Distal Screw Insertion

Pre-op

Fig 3: Functional Outcome at 6 Months

~ 188 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

Post-op at 6 months of tibial shaft fracture: a retrospective follow-up study of

223 cases. J Orthop Trauma. 2014 Sep;28(9):507-12.
2. Weiss RJ, Montgomery SM, Ehlin A, Al Dabbagh Z,
Stark A, Jansson KA. Decreasing incidence of tibial shaft
fractures between 1998 and 2004: Information based on
10,627 Swedish inpatients. Acta Orthop. 2008
Aug;79(4):526-33.
3. Court-Brown CM, Caesar B. Epidemiology of adult
fractures: A review. Injury. 2006 Aug;37(8):691-7.
4. Johal H, Bhandari M, Tornetta P. Cochrane in CORR ®:
Intramedullary Nailing for Tibial Shaft Fractures in
Adults (Review). Clin Orthop. 2017 Mar;475(3):585-91.
5. Rodrigues FL, Abreu DLC, Valenti VE, Valente AL,
Cestari DCPR, Pohl PHI, et al. Bone tissue repair in
patients with open diaphyseal tibial fracture treated with
biplanar external fixation or reamed locked
intramedullary nailing. Injury. 2014 Nov;45(5):S32-35.
6. Inan M, Halici M, Ayan I, Tuncel M, Karaoglu S.
Treatment of type IIIA open fractures of tibial shaft with
Ilizarov external fixator versus unreamed tibial nailing.
Arch Orthop Trauma Surg. 2007 Oct;127(8):617-23.
7. Operative treatment of III grade open fractures of the
tibial diaphysis-PubMed [Internet]. [cited 2024 May 13].
Available from:
Fig 4: Pre-op & Post-op X-ray https://pubmed.ncbi.nlm.nih.gov/16985486/
8. Bhandari M, Zlowodzki M, Tornetta P, Schmidt A,
Conclusion Templeman DC. Intramedullary nailing following
The suprapatellar approach of intramedullary tibial nailing in external fixation in femoral and tibial shaft fractures. J
semi extended position of the knee offers an alternative to the Orthop Trauma. 2005 Feb;19(2):140-4.
traditional infrapatellar approach for tibia diaphyseal fracture. 9. Jones M, Parry M, Whitehouse M, Mitchell S. Radiologic
Specific instrumentation with a cannula system allows for nail outcome and patient-reported function after
insertion in a safe fashion and minimizes the risk of iatrogenic intramedullary nailing: a comparison of the retropatellar
damage to intra-articular structures. In the case of proximal and infrapatellar approach. J Orthop Trauma. 2014
third tibial fractures as well as all diaphyseal tibial fractures, May;28(5):256-62.
the semi-extended position of the knee facilitates fracture 10. Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term
reduction. The suprapatellar approach shows less incidence of follow-up of tibial shaft fractures treated with
anterior knee pain-Suprapatellar approach avoids injury to the intramedullary nailing. J Orthop Trauma. 2008
patellar tendon and infrapatellar nerve, thus helps in avoiding Sep;22(8):525-9.
undesirable postoperative anterior knee pain. It also helping in 11. Toivanen JAK, Väistö O, Kannus P, Latvala K,
achieving good functional outcomes with minimal Honkonen SE, Järvinen MJ. Anterior knee pain after
requirements of secondary procedures at lower complication intramedullary nailing of fractures of the tibial shaft. A
rates in experienced hands provided that proper preoperative prospective, randomized study comparing two different
planning and patient selection are done. This approach nail-insertion techniques. J Bone Joint Surg Am. 2002
supports achieving a reasonably good knee range of Apr;84(4):580-5.
movements and thus helps earlier weight bearing and better 12. Chan DS, Riera SR, Griffing R, Steverson B, Infante A,
functional outcomes at an average of 6 months. Watson D, et al. Suprapatellar Versus Infrapatellar Tibial
Nail Insertion: A Prospective Randomized Control Pilot
Limitations Study. J Orthop Trauma. 2016 Mar;30(3):130-4.
 The follow up period of 6 months is not adequate in a 13. The outcome comparison of the suprapatellar approach
sizable number of patients. A longer follow up would be and infrapatellar approach for tibia intramedullary
better to evaluate postoperative functional outcomes nailing-PubMed [Internet]. [cited 2024 May 13].
more accurately. Available from:
 It was an observational study with Level 5 evidence. A https://pubmed.ncbi.nlm.nih.gov/27154868/
comparative analysis between the suprapatellar approach 14. Serbest S, Tiftikçi U, Çoban M, Çirpar M, Dağlar B.
and other approaches would have provided a superior Knee Pain and Functional Scores After Intramedullary
level of evidence. Nailing of Tibial Shaft Fractures Using a Suprapatellar
Approach. J Orthop Trauma. 2019 Jan;33(1):37-41.
Source of Funding 15. Huang C, Xu ZJ, Wang Q. Short-term clinical effect of
There was no source of funding in our study. tibial fractures which through the patellar approach
intramedullary nail. J N China Univ Sci Technol. 2016;
Conflict of Interest: None 16. Liu Y. Additional note on using suprapatellar nailing
treating tibial fractures. Injury. 2016;6(47):1363-4.
References 17. Yan H, Yuan X. Clinical efficacy of suprapatellar
1. Larsen P, Lund H, Laessoe U, Nielsen GT, Rasmussen S. intramedullary nailing in treatment of tibial shaft fracture.
Restrictions in quality of life after intramedullary nailing World Clin Med. 2016;10(32):65.
~ 189 ~
International Journal of Orthopaedics Sciences https://www.orthopaper.com

18. Fu SP. The therapeutic effect of interlocking

intramedullary nailing via suprapatellar approach in the
treatment of tibial fracture. China Mod Med; c2017.
19. Wang Z, Li SL, Wang XY. Supra-patellar versus infra-
patellar intramedullary nailing in treatment of tibial shaft
fractures. China J Orthop Trauma; c2016.
20. Incidence and aetiology of anterior knee pain after
intramedullary nailing of the femur and tibia-PubMed
[Internet]. [Cited 2024 May 13]. Available from:
https://pubmed.ncbi.nlm.nih.gov/16645100/
21. Knee pain after intramedullary tibial nailing: its
incidence, etiology, and outcome.-Abstract-Europe PMC
[Internet]. [Cited 2024 May 13]. Available from:
https://europepmc.org/article/med/9057144
22. Courtney PM, Boniello A, Donegan D, Ahn J, Mehta S.
Functional Knee Outcomes in Infrapatellar and
Suprapatellar Tibial Nailing: Does Approach Matter? Am
J Orthop Belle Mead NJ. 2015 Dec;44(12):E513-516.
23. Injury to the infrapatellar branch of the saphenous nerve,
a possible cause for anterior knee pain after tibial
nailing?-PubMed [Internet]. [cited 2024 May 13].
Available from:
https://pubmed.ncbi.nlm.nih.gov/21962297/
24. Gaines RJ, Rockwood J, Garland J, Ellingson C, Demaio
M. Comparison of insertional trauma between
suprapatellar and infrapatellar portals for tibial nailing.
Orthopaedics; c2013.

How to Cite This Article

Hemapriya AS, Velmurugan S, Kumar VSV, Anees M. Functional and
radiological outcomes of suprapatellar intramedullary nailing for tibia
diaphyseal fracture-an observational study. International Journal of
Orthopaedics Sciences. 2024;10(2):183-190.

Creative Commons (CC) License

This is an open-access journal, and articles are distributed under the
terms of the Creative Commons Attribution-Non Commercial-Share
Alike 4.0 International (CC BY-NC-SA 4.0) License, which allows
others to remix, tweak, and build upon the work non-commercially, as
long as appropriate credit is given and the new creations are licensed
under the identical terms.

~ 190 ~