Session VII - Knee & Tibia


Sat., 10/10/09 Knee/Tibia, Paper #87, 4:43 pm OTA-2009

Knee Pain after Tibial Nailing Correlates with Union

Scott Ryan, MD (n); Paul Tornetta, III, MD (3,5A, 7-Smith &Nephew; 8-Exploramed);
Cassandra Dielwart, MD (n); Elizabeth Krall Kaye, PhD (n);
Boston University Medical Center, Boston, Massachusetts, USA

Purpose: The most common complication of intramedullary (IM) nailing of tibia fractures is anterior knee pain. While many studies have reported on the incidence of knee pain at final follow-up, little is known about the change in knee pain over time during healing. The purpose of this study is to evaluate the change in quantitatively scored knee pain during union.

Methods: Over a 15-year period, all patients who sustained either a closed or open tibia fracture treated with an IM nail were evaluated prospectively for knee pain and union at each follow-up visit. Patient-based knee pain was scored from 0 to 3 according to Court-Brown et al (0 = none, 1 = mild, 2 = moderate, and 3 = severe). Fracture union was also graded, using a modified Hammer score based on cortical bridging and remodeling. This score was stratified into 4 categories for statistical analysis (0 = no healing, 1 = callus present, 2 = bridging callus, and 3 = remodeling present). The time from surgery was also recorded. Statistical analysis was performed with multivariate generalized estimating equations to determine if there was any relationship between quantitative knee pain and either union score, or time from surgery. Prior to the statistical analysis, 2 subgroup analyses were planned based on prior reports. One was age (<40 vs ≥40 years) and the other, gender.

Results: 428 patients (330 male; 98 female) aged 16 to 87 years (mean 38 ± 15 years) with 443 tibia fractures (228 open, 215 closed) treated with IM nails had sufficient data points to be included. 69% of patients reported anterior knee pain at some point during their follow-up period. We found a significant inverse association between pain and union score (P <0.01). In contradistinction, there was not a correlation between pain and time from surgery (P = 0.53). As union score and time were related, a model was created with both parameters. This model demonstrated a statistical correlation with union score (P <0.01), but not with time from surgery (P = 0.18). Subgroup analyses demonstrated that younger patients (<40 years of age) showed a steeper, statistically significant (P <0.01) decline in pain score as union increased as compared to older (≥40 years) patients (P = 0.15). Gender did not affect the correlation of knee pain to either union or time (power 81%).

Conclusions: The etiology of anterior knee pain after tibial nailing is multifactorial. We postulated that knee pain may correlate with either union or time from surgery. In this series of 443 tibia fractures treated with IM nailing, there was a statistically significant, negative correlation between knee pain and fracture union, ie, as the fracture heals, knee pain improves. There was no such association between pain and time from surgery. Additionally, younger patients had a steeper drop in pain with union than older patients, and gender did not affect these results.


Disclosure: (n=Respondent answered 'No' to all items indicating no conflicts; 1=Board member/owner/officer/committee appointments; 2=Medical/Orthopaedic Publications; 3=Royalties; 4=Speakers bureau/paid presentations; 5A=Paid consultant or employee; 5B=Unpaid consultant; 6=Research or institutional support from a publisher; 7=Research or institutional support from a company or supplier; 8=Stock or Stock Options; 9=Other financial/material support from a publisher; 10=Other financial/material support from a company or supplier).

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant