Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis

Abstract

Background: Intramedullary nailing (IMN) is a conventional technique for the treatment of tibial shaft fractures. It has been suggested that the suprapatellar (SP) approach holds advantages over the traditional infrapatellar (IP) approach. Current literature lacks adequate data to provide robust clinical recommendations. This meta-analysis aims to determine the efficacy of infrapatellar versus suprapatellar techniques for IMN.

Methods: An up-to-date literature search of the Embase, Medline, and registry platform databases was performed. The search was conducted using a predesigned search strategy and all eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. Fluoroscopy time, operative time, pain score, knee function, deep infection, non-union and secondary operation rates were all considered.

Conclusion: A total of twelve studies were included in the meta-analysis. The results of this analysis show that suprapatellar nailing is associated with reduced post-operative pain scores and improved functional outcomes. The data suggest no significant difference in terms of operative times, fluoroscopy times, rates of deep infection, non-union or secondary procedures when compared to infra-patellar techniques. Further studies are required to confirm these findings and assess long-term results.

Keywords: Fixation; Infrapatellar; Suprapatellar; Tibia fracture.

Fig. 1

The Preferred Reporting Items for Systematic reviews and Meta-analysis

Fig. 2

The risk of bias graph of the included studies. The colour represents the quality in the each of the domains (high = high risk, unclear = uncertain and low = low risk)

Fig. 3

The risk of bias for each of the included studies. The colour represents the quality in each of the domains (red = high risk, yellow = uncertain and green = low risk)

Fig. 4

Forest plots of the comparison of fluoroscopy time between the two approaches. Abbreviations: CI, confidence interval; IV, independent variable; M-H:, Mantel-Haenszel

Fig. 5

Forest plots of the comparison of operation time. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel

Fig. 6

Forest plots of the comparison of pain scores. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel

Fig. 7

Forest plots of the comparison of knee functional scores. (a) Lysholm scores, (b) HSS scores, (c) Kujala scores and (d) OKS respectively. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel

Fig. 8

Forest plots of the comparison of deep infection. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel

Fig. 9

Forest plots of the comparison of non-union rate. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel

Fig. 10

Forest plots of the comparison of secondary operation. Abbreviations: CI, confidence interval; IV, independent variable; M-H, Mantel-Haenszel