Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis

Abstract

Background: This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing.

Method: This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data.

Results: Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00).

Conclusions: With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures.

Level of evidence: Level III, systematic review of non-randomized studies.

Keywords: Distal tibia fracture; Infrapatellar; Intramedullary nailing; Suprapatellar; Tibia fracture.

Fig. 1

PRISMA flow diagram of the study

Fig. 2

Forest plot of pain at 1 year after surgery. There was no significant difference between the two groups concerning the level of pain reduction (SMD: − 0.92, 95% CI − 3.19 to 1.35; P = 0.43; I² = 98%). MD median difference, CI confidence interval

Fig. 3

Forest plot of knee function by Lysholm score 12 months after surgery. The SP group had a higher Lysholm score than the IP group (MD: 3.90 points; 95% CI 0.83 to 5.36; P = 0.007; I² = 0%). MD median difference, CI confidence interval

Fig. 4

Forest plot of ankle function assessed by the AOFAS score 12 months after surgery. The SP group had a clinically significantly higher AOFAS score than the IP group (MD: 8.25 points; 95% CI 3.35 to 13.15; P = 0.001; I² = 91%). AOFAS American Orthopedic Foot and Ankle Society, MD median difference, CI confidence interval

Fig. 5

Forest plots of a coronal angulation and b sagittal angulation. Compared to SP, IP had greater coronal angulation (MD: − 2.09°; 95% CI − 2.47 to − 1.71; P < 0.001; I² = 75%) but similar sagittal angulation (MD: − 1.40°; 95% CI − 3.43 to 0.64; P = 0.18; I² = 99%). CI confidence interval, MD mean difference

Fig. 6

Forest plot of the malalignment. The SP group had a lower risk for postoperative malalignment than the IP group (OR: 0.22; 95% CI 0.06 to 0.75; NNT: 6 (95% CI 5 to 20); P = 0.02; I² = 77%). CI confidence interval, NNT number needed to treat, OR odds ratio

Fig. 7

Forest plot of the need for open reduction. The SP group had a lower risk for open reduction than the IP group (OR: 0.58; 95% CI 0.35 to 0.97; NNT: 16 (95% CI 10 to 233); P = 0.04; I² = 0%). CI confidence interval, NNT number needed to treat, OR odds ratio

Fig. 8

Forest plot of the surgical time. The SP group had a shorter surgical time than the IP group (MD: − 15.14 min; 95% CI − 21.28 to − 9.00; P < 0.001; I² = 59%). CI confidence interval; MD mean difference