Assessment of functional and radiological outcomes of suprapatellar and infrapatellar approaches of tibial nailing in patients with tibial shaft fracture: A randomized control study

Abstract

Background: The study aimed to assess functional and radiological outcomes of the suprapatellar approach (SPA) and infrapatellar approaches (IPA) of tibial nailing in patients with closed tibia shaft fractures.

Method: After Institutional Ethical Committee (IEC) and Clinical Trials Registry- India (CTRI) approval, patients with Orthopaedic Trauma Association (OTA) fracture type 42 were enrolled from August 2021 and August 2022 at a level I trauma centre and randomized to SPA and IPA with informed consent. Demographics, American Society of Anaesthesiologists (ASA) physical grading, intraoperative fluoroscopy time, operative duration, bleeding, postoperative radiographic alignment, and union were compared among both approaches. Functional parameters like Lysholm knee score, Anterior knee pain (AKP), Visual Analog Scale (VAS) Score upon kneeling, Knee Injury and Osteoarthritis outcome score (KOOS), KOOS Patellofemoral score (KOOS PF), EuroQol (EQ5D5L), Forgotten joint score (FJS), Range of motion (ROM) of knee and any complications were assessed at 3,6 and 12 months postoperatively.

Results: Per protocol analysis of 50 patients (25 SPA, 25 IPA) done at the end of the study. SPA group had significantly lesser fluoroscopy time (91.28 ± 12.40s vs. 105.36 ± 9.23s, p < 0.001) and operative duration (mins) (123.80 ± 24.25 vs. 130.00 ± 18.20, p < 0.001) than IPA. No significant differences were noted in Lysholm knee score at three months (p = 0.094), six months (p = 0.406), and 12 months (p = 0.071). The SPA group showed significantly lower VAS Score upon kneeling at six months (p < 0.0001). Similarly, KOOS (p < 0.001), KOOS PF (p = 0.01), and EQ 5D5L (p = 0.03) were significantly better in the SPA group at six months postoperatively. Lower Coronal translation was found in SPA [0 (0-1.8) vs. 1.4 (0.9-1.8), p = 0.010]. Whereas, IPA had higher range of flexion at 3 months [130.0 (129.0-135.0) vs 123.1 (120.0-130.5), p = 0.047]. However, no significant differences were noted in blood loss, AKP, FJS, EQ-VAS, coronal angulation, sagittal malalignment, time to union, return to work and postoperative complications among the groups.

Conclusion: SPA has lesser surgery time, more straightforward anatomic fracture reduction, better fracture alignment, lesser radiation exposure for both patients and surgeons, quicker recovery time, and promotes early kneeling activities with similar long-term functional outcomes and union rates, and can be considered in routine clinical practice than conventional IPA.

Keywords: Infrapatellar approach; Suprapatellar approach; Tibia nailing; Tibia shaft fracture.

Fig. 1

CONSORT flow diagram of patients.

Fig. 2

Suprapatellar Approach; Semi-extended position (A), Insertion of the trocar with a silicone sleeve in a semi-extended position (B), Fluoroscopy in AP view (C) and lateral view (D), Reaming in semi-extended position in Suprapatellar approach (E), nail length measurement (F) and Irrigation of joint with normal saline (G).

Fig. 3

Suprapatellar Approach radiographs; pre-op (A), Immediate post-op (B), 3 months follow-up (C), 6 months follow-up (D), 12 months follow-up (E), clinical picture with patient sitting cross-legged (F), kneeling (G).

Fig. 4

Suprapatellar Approach radiographs; pre-op (A), Immediate post-op (B), 3 months follow-up (C), 6 months follow-up (D), 12 months follow-up (E), clinical picture with patient sitting cross-legged (F), squatting (G), kneeling (H).

Fig. 5

Infrapatellar Approach radiographs; pre-op (A), Immediate post-op (B), 3 months follow-up (C), 6 months follow-up (D), 12 months follow-up (E), clinical picture with patient sitting cross-legged (F), kneeling (G).

Fig. 6

Infrapatellar Approach radiographs; pre-op (A), Immediate post-op (B), 3 months follow-up (C), 6 months follow-up (D), 12 months follow-up (E), clinical picture with patient sitting cross-legged (F), squatting (G), kneeling (H).