Comparison of Infrapatellar and Suprapatellar Intramedullary Nails with New Clinical Score for Fixation of Tibial Shaft Fractures

Abstract

Objectives: Tibial shaft fractures (TSFs) represent the most common diaphyseal fractures in adults. The gold-standard treatment is intramedullary nailing. Recently, the suprapatellar technique has been increasingly adopted due to its ability to reduce complications associated with the infrapatellar approach. Currently, no clinical score for leg fractures comprehensively assesses the entire lower limb. Therefore, we reviewed the main lower-limb scores available in the literature and developed a new clinical evaluation tool for tibial shaft fractures. The aim of our study was to report our experience with both techniques, to compare the outcomes of our prospective study with the international literature, and to propose a new, easy-to-apply, and reproducible clinical score that evaluates the specific functions of the entire lower limb. Methods: We conducted a prospective analysis of 920 tibial shaft fractures treated with intramedullary nailing via either a suprapatellar or infrapatellar approach. Patients were divided into two groups: Group A, including 420 patients treated with the infrapatellar approach; Group B, including 500 patients treated with the suprapatellar approach. Follow-up included clinical and radiographic assessments at 1, 3, and 6 months, and annually thereafter. We evaluated differences in patient positioning, operation time, radiation exposure, healing rate, incidence of pseudarthrosis and infection, return to ambulation, residual knee pain and fracture site, persistent lameness, and deformities. For the clinical assessment, we devised a new score-the Catania Hospital Score (CHS)-by integrating the most relevant clinical items from existing lower-limb evaluation tools. The CHS includes anterior knee pain (20 points), lameness (5 points), swelling (10 points), stair-climbing ability (10 points), tibial pain (15 points), the ability to perform daily activities (20 points), and evaluation of deformities (varus/valgus, shortening, rotation, and recurvatum/procurvatum (40 points)), for a total of 120 points. Results: Statistically significant differences were observed in Group B regarding a shorter surgical time, a reduced patient positioning time, and decreased radiation exposure. The CHSs were significantly better for Group B at the 3- and 6-month follow-ups. No statistically significant differences were found in infection or pseudarthrosis rates between the two groups. Notably, no cases of chronic knee pain were reported in patients treated with the suprapatellar approach. Conclusions: Both surgical approaches are valid and effective. However, our findings indicate that the suprapatellar approach reduces the complications of the infrapatellar technique, improves postoperative outcomes, and does not result in chronic knee pain. The CHS provides a comprehensive, practical, and reproducible tool to assess functional recovery in patients treated with intramedullary tibial nailing.

Keywords: infra–suprapatellar comparison; new clinical score; tibial fractures.

Figure 1

The image shows the positioning of the patient for infrapatellar intramedullary nailing. It is important to note the knee flexion between 90° and 100°, which facilitated access to the tibial canal and fracture alignment. In our study, patients were placed on a traction table using transkeletal traction at the calcaneus. A padded support was placed at the level of the popliteal fossa to maintain stable flexion.

Figure 2

The image shows the patient positioning for suprapatellar intramedullary nailing. Compared with the infrapatellar technique, this positioning was significantly simpler. Patients were placed supine on a radiolucent operating table, with their knee in a semi-extended position (with approximately 10–20° of flexion), allowing easier access to the tibial entry point without the need for deep knee flexion or complex supports.