Session I - Tibia

Anterior Knee Pain after Intramedullary Nailing of the Tibia: Are Knee Function and Work Problems in the Long Term?

Kevin T. Boyd, FRCS; Richard J. Tippett, MBBS; Christopher G. Moran, MD, FRCS, University Hospital, Queen's Medical Centre, Nottingham, U.K.

Purpose: We assessed the prevalence of anterior knee pain more than 5 years after closed intramedullary nailing of the tibia. Knee function and the ability to return to previous or gainful employment was evaluated to assess the long-term socioeconomic impact of this common complication.

Method: This retrospective cohort study assessed 298 consecutive tibial intramedullary nailing procedures performed in 295 patients from 1990 to 1994 with use of an AO locked intramedullary nail. Minimum follow-up was 5 years. Patients were asked to complete a questionnaire, and their knee status was evaluated with the Lysholm knee score. Twenty-six patients died, and 22 patients who remained alive but who were more than 60 years of age at the time of their injury were excluded. Thus, 251 knees in 248 patients were available for review.

Results: The mean age at follow-up was 41 years (range, 22 to 68). The ratio of men to women was 5:1, and the mean follow-up was 8 years (range, 6 to 11). Anterior knee sensory disturbance was reported by 58% of the patients, and it interfered with activities of daily living (ADL) in 29%, with work in 25%, and in sport in 37%. Anterior knee pain was reported by 47% of patients, and it interfered with ADL in 37%, with work in 36%, and in sport in 57%. Anterior knee pain was present all the time in 4% of patients, often in 12%, sometimes in 27%, rarely in 21%, and never in 37%. Pain on kneeling was rated on a visual analogue scale as mild in 54% of patients, moderate in 34%, and severe 12%. Anterior knee pain improved with time in 73% of the patients and became worse in 4%. The Lysholm score rating for 41% of the knees was excellent, for 19% it was good, for 26% it was fair, and for 14% it was poor. Eighty-six percent of the patients have been able to return to work, 9% are currently unemployed, and 5% are disabled. Ten percent of the patients felt that the presence of anterior knee pain prevented return to their previous work. The type of work performed before and after injury, respectively, was sedentary 26%/29%, walking-based 20%/27%, manual 38%/37%, and heavy manual 16%/7%.

Discussion: The causation of anterior knee pain after intramedullary nailing of the tibia remains uncertain. Although anterior knee pain seems to decline with time, it was still found in nearly half of our patients after almost 8 years, causing limitation in ADL and work for nearly a fifth of patients. Sixteen percent of the patients had undergone implant removal because of anterior knee pain. Although many of the knees were rated as good or excellent, a significant proportion of patients have had poor outcomes. It is likely that a number of these patients had occult knee or additional injuries that may have contributed to their knee pain and functional limitations. However, the high prevalence of anterior knee pain more than 5 years after intramedullary nailing for tibial shaft fractures is a cause for concern.

Conclusion: Anterior knee pain persisted in 47% of patients after intramedullary nailing of the tibia. There was some decrease in symptoms with time, and the majority of patients were able to return to work and perform activities of daily living. However, anterior knee pain causes a significant disability in a small number, and all patients should be routinely warned of this problem prior to the surgical procedure.