Insertion site for intramedullary tibial nails, and its relationship to anterior knee pain

Abstract

Recent work has suggested that a patella tendon splitting approach for insertion of intramedullary tibial nails is associated with an increased incidence of anterior knee pain. We looked at 47 patients with 48 tibial fractures stabilised with intramedullary nails. Four nails were unreamed, the rest reamed. Thirty-five fractures were closed, eight Gustillo type 1, three type 2 and two type 3. Information about insertion approach and knee pain was available for 38 patients. Fifty percent had anterior knee pain, 22 had a medial approach performed, 12 had pain, 16 had a patella tendon splitting approach, seven had pain (NS, χ2=0.43). Suitable X-rays were available to allow measurement of patella tendon shortening in 30 patients (patella included on X-ray view). This demonstrated patella tendon shortening of 2.8% in the pain group (n=14); 3.4% in the no pain group (n=16); 3.3% in the split group (n=10); and 3.5% in the medial approach group (n=17, information on surgical approach not available for three patients). The range of shortening for all patients did not exceed 10%. The literature suggests that patella tendon shortening can occur with excessive dissection required for a medial approach at this area of the knee. We agree with recent comments that a controlled trial is required to evaluate this problem further.