Sat., 10/6/12 Tibial Fractures, PAPER #115, 4:09 pm OTA-2012
Intramedullary Nailing of the Tibia via a Suprapatellar Approach: Radiographic Results and Clinical Outcomes at a Minimum of 12 Months Follow-up
Charles J. Jordan, MD; Thomas G. DiPasquale, DO; H. Claude Sagi, MD;
John A. Arrington, MD; Roy Sanders, MD;
Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, Florida, USA
Background/Purpose: Intramedullary (IM) nailing of the tibia has historically been performed through an infrapatellar approach with the knee flexed. Difficulty with fracture alignment and knee pain are known complications of this technique. A suprapatellar (SP) entry portal has been developed to allow positioning of the limb in a semiextended position, thus facilitating fluoroscopic imaging and maintenance of fracture reduction. Additionally, infrapatellar knee pain is reported to be decreased. The technique, however, remains controversial due to the necessity of instrument and implant insertion through the patellofemoral (PF) joint. The purpose of this study was to determine the incidence of both chondral damage to the PF joint and knee pain, knee range of motion (ROM), and fracture healing with the SP technique.
Methods: 40 consecutive patients (40 fractures) with an extra-articular tibia fracture confined to the middle 3/5 of the tibia (OTA 42A-C) underwent locked, reamed, SP IM nailing using specially designed instruments for this technique. All patients were skeletally mature. Patients were evaluated clinically and radiographically at 1, 3, 6, and 12-month intervals. Functional outcomes (Short Form 36 [SF-36], Lysholm knee score, visual analog pain (VAS), knee ROM, and a diagram documenting location of pain) were collected by an independent third party at 6 and 12 months. MRI of the knee was performed at 12 months, and independently reviewed by a board certified, fellowship-trained musculoskeletal radiologist.
Results: Patients were followed for a minimum of 1 year (range, 12-49 months). All fractures healed, and no angular or length deformity was seen. The median Lysholm knee score at final follow-up was 82.5 (range, 20-100). Mean SF-36 physical and mental component summary scores were 40.8 (standard deviation [SD] 9.7) and 46.0 (SD 11.7), respectively. Mean arc of knee motion was 121.3° (SD 15.5°) for the affected extremity compared with 125.9° (SD 17.5°) for the contralateral knee. 36 of 40 patients (90%) had no knee pain whatsoever. Four patients (10%) were found to have knee pain. Two patients had joint line pain (with known meniscal tears), and two patients had tenderness associated with a proximal locking screw). Importantly, no patients complained of PF joint pain. By MRI, no patients were found to have changes in the PF cartilage attributable to the surgical technique.
Conclusion: Our data from this prospective analysis indicate that an SP entry portal is a safe site for tibial nail insertion in the treatment of tibial shaft fractures. Knee pain secondary to damage to the PF cartilage did not occur, and was, in fact, significantly lower than that reported historically for the infrapatellar technique. Moreover, we were unable to demonstrate any deleterious effects on the articular cartilage of the PF joint with MRI at 1 year postprocedure. An OTA-sponsored randomized controlled trial is presently underway to further define the role of this technique for the management of OTA 42A-C fractures.
Funding: This work was aided by a grant from Stryker Orthopaedics and the Tampa General Foundation
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• 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.