Infrapatellar Approach Research Articles

Management of distal tibial metaphyseal fracture by expert tibial nail using suprapatellar approach

Background: Distal tibial metaphyseal fractures are common lower limb injuries and results in extensive musculoskeletal damage due to paucity of soft tissue coverage. Fixation methods include open reduction and internal fixation (ORIF) with plates, minimally invasive percutaneous plate osteosynthesis (MIPPO) and intrameduallary nailing. Extensive exposure for ORIF leads to wound complications,nonunion and infection. Intramedullary nailing is the preferred for diaphyseal tibial fracture however conventional nailing is less suited for distal tibial metaphysis due to diameter mismatch between the nail and the bone leading to very little nail effect and impaired stability. Expert tibial nail with multiplanar locking options at the proximal and distal end allows for secure stabilization of the metaphyseal fragments. Infrapatellar approach is traditionally used for tibial nailing however suprapatellar approach is emerging as an alternative as semi-extended positioning makes it technically easier to nail the proximal and distal fractures. Materials and Methods: This is a prospective study conducted from February 2019 to February 2020. 14 patients fulfilling the inclusion criteria underwent intramedullary nailing using the suprapatellar approach. The functional outcomes were measured at 6 months using the Lysholm knee score and the SF-36 physical and mental score. The obtained data was analyzed using SPSSv16. Result: The average time of fracture union was 17.8 weeks. The mean SF-36 physical and mental score were 42.4 and 44.5 respectively. The average Lysholm score was 84. The mean arc of motion in the involved knee was 110ᵒ. Secondary procedure in the form of dynamization was done in 2 cases. Anterior knee pain was observed in 3 patients.Conclusion: Expert tibial nailing using suprapatellar approach appears to be a suitable fixation method for distal tibial metaphyseal injuries as it provides good functional and clinical outcome at the same time minimizing the violation of delicate soft tissue structures.

Intramedullary tibial nailing using infrapatellar and suprapatellar approaches: A systematic review and meta-analysis

IntroductionIntramedullary nailing of diaphyseal tibial fractures has become the gold standard method of fixation with high rates of union and low complication rates reported. The suprapatellar (SP) approach may have many advantages over the traditional infrapatellar (IP) approach. Controversy exists due to potential damage to the patellofemoral joint leading to persistent anterior knee pain. This systematic review and meta-analysis aims to evaluate the clinical and procedural outcomes of the SP approach in comparison to the traditional IP approach. MethodIn this PRISMA compliant systematic review and meta-analysis, five databases including MEDLINE, EMBASE, Web of Science, Cochrane Library and CINAHL were searched from inception until May 2020. Randomised controlled trials (RCTs) and comparative observational studies involving adults with tibial fractures treated with intramedullary nail fixation using either the suprapatellar or infrapatellar approach were included. Data extracted included demographics, functional knee scores, fluoroscopy exposure, insertional accuracy and adverse events. The primary outcome was validated functional knee scores. Risk of bias was calculated using the Cochrane risk of bias tool version 2 (RoB 2) and Newcastle-Ottawa Scale (NOS). ResultsIn total 16 studies were included consisting of 5 RCTs and 11 comparative observational studies. This included 1750 total operations with 810 in the SP group and 940 in the IP group. Meta-analysis was performed on the studies where appropriate data was reported. The SP approach demonstrated superior Lysholm scores (Mean Difference (MD) 5.63 [95% Confidence Interval (CI): 2.81 to 8.44]), reduced fluoroscopy times (MD -38.12 sec [95% CI: -47.96 to -28.28]) and increased entry point accuracy (Standard Mean Difference (SMD) -0.90 [95% CI: -1.22 to –0.59]). No differences in complication rates or blood loss were found. ConclusionBased on the data presented in this review, intramedullary nailing of the tibia using the SP approach demonstrates superior Lysholm knee scores, greater entry point accuracy and reduced fluoroscopy exposure with equivalent risk of developing complications when compared to the IP approach.

Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures

BackgroundThis study aimed to analyze and compare the clinical and functional outcomes of distal tibia fractures treated with intramedullary nailing (IMN) using the suprapatellar (SP) and infrapatellar (IP) surgical approaches.MethodsA retrospective analysis was performed in 63 patients with distal fractures that were treated with IMN between August 2014 and August 2018. A total of 27 and 36 patients underwent IMN using the SP and IP techniques, respectively. The surgical time, blood loss, closed reduction rate, rate of adjuvant reduction technique, fracture healing time, and complications were reviewed in this study. Anterior knee pain was assessed using the visual analog scale. The Lysholm Knee Scoring Scale and American Orthopaedic Foot and Ankle Society (AOFAS) scale were used as clinical measurements.ResultsA total of 63 patients, with a minimum follow-up of 12 months, were evaluated. The average surgical time, blood loss, rate of adjuvant reduction technique, closed reduction rate, fracture healing time, and Lysholm Knee Scoring Scale score were insignificantly different (P > 0.05) between the two groups. However, the SP approach was superior to the IP approach in terms of pain score, AOFAS score, and fracture deformity rate (P < 0.05).ConclusionsIn the treatment of distal tibia fractures, the SP IMN technique is associated with a significantly higher functional outcome, lower knee pain, and lower rate of fracture deformity than the IP IMN technique.

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures.

To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach. Retrospective chart review. Level 1 trauma center. Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018. A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders. Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores. There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores. Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach.Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 – 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores.Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1).Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Current treatment strategies for lower leg fractures in adults

Shaft fractures of the tibia and fibula mainly affect younger patients and are therefore of great socioeconomic importance. Due to the high proportion of high-energy direct trauma mechanisms and the thin soft tissue covering layer of the ventromedian tibia, open factures occur in up to 39%. Astructured diagnostic and therapeutic approach is essential for successful treatment. Reamed intramedullary nailing is currently the gold standard surgical procedure. The suprapatellar approach, representing an interesting alternative to the popular infrapatellar approach, postoperative complications, such as anterior knee pain as well as the management of non-unions are discussed in this article. Furthermore, the indications and the application of minimally invasive plate osteosynthesis (MIPO) and external fixators are described. Every trauma surgeon should be familiar with the etiology and the surgical treatment of compartment syndrome. Afirm knowledge of the classifications of open and closed soft tissue injury is mandatory.

Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures.

Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures.

Ultrasonographic Characteristics of the Stifle Joint in Clinically Normal Donkeys (Equus asinus)

Stifle ultrasonography is a widely accepted diagnostic tool that has been used for diagnosing articular and peri-articular stifle injuries in horses. Limited information is available regarding the ultrasonographic appearance of the stifle joint in donkeys. The aim of the present study was to describe the normal ultrasonographic characteristics of the stifle joint in clinically normal donkeys. A descriptive study was done on 15 clinically normal donkeys (30 joints). Ultrasonographic examination was done in a systematic manner including both supra- and infra-patellar regions. The patella, patellar ligaments and tibial tuberosity were taken as palpable anatomical landmarks for localization of different stifle structures. A detailed description of the ultrasonographic appearance of the quadriceps muscle, supra-patellar pouch and femoropatellar joint was done through the supra-patellar approach. In infra-patellar approach, thepatellar ligaments, medial and lateral femorotibial joints, collateral ligaments, menisci, origin of peroneous tertius and popliteal tendon were described. Standardized, repeatable and reliable images were achieved from both approaches. Ultrasonography provided a clinically useful tool for diagnosing donkeys with stifle joint disease.

Suprapatellar versus infrapatellar approaches in the treatment of tibia intramedullary nailing: a retrospective cohort study

BackgroundTibial shaft fractures are routinely managed with intramedullary nailing (IMN). An increasingly accepted technique is the suprapatellar (SP) approach. The purpose of this study was to compare the clinical and functional outcomes of knee joint after tibia IMN through an suprapatellar (SP) or traditional infrapatellar (IP) approach.MethodsRetrospective analysis was performed in patients with tibial shaft fractures that were treated with IMN through a SP or IP approach between 01/01/2014 and 31/12/2016. The clinical and functional outcomes of the knee were assessed with the Hospital for Special Surgery (HSS) Knee Score. Secondary outcomes included the operation time and intraoperative blood loss.ResultsA total of 50 patients/fractures (26 IP and 24 SP) with a minimum follow-up of 15 months were evaluated. All fractures were OTA 42. No significant differences were found between the two groups in age, gender, side of fractures, operation time, intra-operative blood loss, and follow-up time. No significant difference was seen in HSS score (P = 0.62) between them. Sub analysis of all the HSS components scores revealed no significant differences between pain (P = 0.57), the stand and walk (P = 0.54), the need for walking stick (P = 0.60) and extension lag (P = 0.60). The other HSS components showed full scores (IP 10 vs. SP 10) in both approaches, including muscle force, flexion deformity and stability components. The range of motion (ROM) component score was superior in the IP group (P = 0.04) suggesting a higher ROM.ConclusionsBoth SP and IP approach results in equivalent overall HSS knee scores. However, for the HSS component, the IP approach was superior to SP approach regarding the ROM.

Efficacy of suprapatellar versus infrapatellar approach in tibial intramedullary nail fixation for tibial fracture: a systematic review and meta-analysis

Objective To investigate the efficacy of suprapatellar versus infrapatellar approach in tibial intramedullary nail fixation for tibial fracture. Methods Clinical trials that evaluated suprapatellar approach and infrapatellar approach for tibia intramedullary nailing fixation were searched in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Chinese Biology Medicine (CBM), Wanfang, Weipu and CNKI databases. Methodological qualities of the included studies were assessed using the Cochrane Collaboration tool and Newcastle-Ottawa Scale. Sensitivity analyses were performed to determine whether overall results were reliable. Publication bias was detected using Begg's test and Egger's test. Lysholm score, reoperation rate, Hospital for Special Surgery (HSS) score, operation time, intraoperative blood loss and hospital stay were selected to evaluate the clinical effect of suprapatellar approach and infrapatellar approach in tibial intramedullary nail fixation for tibial fracture. Results Two randomized controlled trials and six case-controlled studies involving 787 patients were included in the analysis. Sensitivity analyses indicated that the results were statistically significant. No significant publication bias was detected by Begg's test or Egger's test. Our meta-analysis indicated that suprapatellar approach had significantly higher Lysholm score (MD=1.04, 95%CI 0.82-1.26, P 0.05). Conclusion Compared with infrapatellar approach, suprapatellar approach in intramedullary nail fixation for tibial fracture can better relieve the pain, keep stability and motion of the knee joint and promote function recovery of knee joint. Key words: Tibial fractures; Fracture fixation, intramedullary; Suprapatellar approach

Suprapatellar tibial nailing: a learning curve analysis.

The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the UnitedKingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

Intramedullary nailing through a suprapatellar approach. Evaluation of clinical outcome after removal of the device using the infrapatellar approach.

Background and aim of the work: Since 2006, It has been developed the possibility to introduce a tibia nail through a suprapatellar access. However, the removal of device must be carried out using the classic infrapatellar approach. The aim of this study is to evaluate the clinical scores of a group of patients that removed a tibial nail by infrapatellar approach, previously introduced through a suprapatellar access. Methods: Seven patients received removal, through infrapatellar access, of tibial nail previously introduced by suprapatellar approach. Despite being VAS <5, patients requested the device to be removed. The variables studied were the distance between the apex of the nail and the tibial plateau (TPD) and between the apex of the nail and the anterior tibia (ATD), oxford knee score (OKS), Kujala score (KJS), Visual Analog Scale (VAS) and SF 36 before surgery and 1 year. A1 year of follow up the Sidky-Buckley questionnaire was administered. The follow-up was 1 year. Results: The mean VAS was 2.8 before surgery and 0.5 at 1 year after surgery, OKS average pre-surgery is 38 (good), while at 1 year it becomes 44 (excellent). The Sidky-Buckley questionnaire showed that all patients would have the intramedullary nail removed again. The widest improvement in all parameters is seen in the two patients with less distance from the tibial plateau. Conclusions: Although the patients had received initial suprapatellar access and a second infrapatellar for the removal of the device, no complications were reported regarding the use of the two accesses. (www.actabiomedica.it)

Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: a systematic review and meta-analysis

BackgroundOptimal surgical approach for tibial shaft fractures remains controversial. We perform a meta-analysis from randomized controlled trials (RCTs) to compare the clinical efficacy and prognosis between infrapatellar and suprapatellar intramedullary nail in the treatment of tibial shaft fractures.MethodsPubMed, OVID, Embase, ScienceDirect, and Web of Science were searched up to December 2017 for comparative RCTs involving infrapatellar and suprapatellar intramedullary nail in the treatment of tibial shaft fractures. Primary outcomes were blood loss, visual analog scale (VAS) score, range of motion, Lysholm knee scores, and fluoroscopy times. Secondary outcomes were length of hospital stay and postoperative complications. We assessed statistical heterogeneity for each outcome with the use of a standard χ2 test and the I2 statistic. The meta-analysis was undertaken using Stata 14.0.ResultsFour RCTs involving 293 participants were included in our study. The present meta-analysis indicated that there were significant differences between infrapatellar and suprapatellar intramedullary nail regarding the total blood loss, VAS scores, Lysholm knee scores, and fluoroscopy times.ConclusionSuprapatellar intramedullary nailing could significantly reduce total blood loss, postoperative knee pain, and fluoroscopy times compared to infrapatellar approach. Additionally, it was associated with an improved Lysholm knee scores. High-quality RCTs were still required for further investigation.

Suprapatellar versus infrapatellar intramedullary nailing for tibal shaft fractures: A meta-analysis of randomized controlled trials.

Background and Objective:The aim of this study was to compare the outcome of using tibial nails inserted by the suprapatellar approach with tibial nails inserted by the infrapatellar approach in a meta-analysis of randomized controlled trials (RCTs).Methods:The following electronic databases were searched: PubMed (1966 to January 2018), EMBASE (1974 to January 2018), Cochrane Library (January 2018), Web of Science (1990 to January 2018). We also used Google Search Engine to search more potentially eligible studies until January 2018. The methodological qualities of included studies were assessed in accordance with the guidelines provided by the Cochrane Collaboration for Systematic Reviews. The statistical analysis all of included studies were performed by STATA 13.0 software. The outcomes were total blood loss, postoperative pain, range of motion (ROM), Lysholm knee score, fluoroscopy time, operation time, and postoperative complications.Results:Four RCTs published between 2015 and 2017 were selected in the meta-analysis. There was a significant difference between suprapatellar and infrapatellar approach surgery in total blood loss, postoperative pain, ROM, Lysholm knee scores, and fluoroscopy times.Conclusions:The suprapatellar approach for intramedullary nailing appears superior to the infrapatellar approach, with a reduction in total blood loss, improved postoperative pain, shorter fluoroscopy time, and better knee functionality outcomes. There was no increased incidence of postoperative complications between the 2 groups. Further research remains necessary.

Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures

During intramedullary nailing of tibial fractures, the insertion angle of the nail is of great importance. When the nail impacts the posterior cortex due to a large insertion angle with a dorsal target course, higher insertion forces are needed, and the danger of iatrogenic fractures increases. Accordingly, the insertion direction should be as parallel as possible to the longitudinal axis of the tibia. We aimed to confirm the hypothesis that intramedullary nailing of tibial fractures can be performed with smaller insertion angles via a suprapatellar approach rather than infrapatellar approach. In 19 human bodies of donors with intact tibiae, we performed intramedullary nailing by both a suprapatellar and an infrapatellar approach. The correct entry point was determined by fluoroscopy. Subsequently, the medullary canal was reamed up to a diameter of 10mm, and a 9mm polytetrafluorethylen tube was inserted instead of a tibia nail. The angle between the proximal aspect of the tube and the longitudinal axis of the tibia was measured using a computer-assisted surgery system. The angle between the proximal aspect of the inserted tube, simulating the tibial nail, and the longitudinal tibial axis was significantly larger when using the infrapatellar approach. We achieved an insertion angle significantly more parallel to the longitudinal axis when using a suprapatellar approach for intramedullary nailing of tibial fractures. Thereby, both the risk of iatrogenic fracture of the posterior cortex and apex anterior angulation of the short proximal fragment can be reduced during intramedullary nailing of tibial fractures.

Supra-patellar versus infra-patellar intramedullary nailing in treatment of tibial shaft fractures

Objective To compare the clinical efficacy and prognosis between classical infra-patellar (IP) and supra-patellar (SP) intramedullary nailing in the treatment of tibial shaft fractures. Methods A retrospective analysis was conducted of the 68 patients with tibial shaft fracture who had been treated from June 2012 to December 2014 and completed follow-ups. They were 59 males and 9 females, 18 to 87 years of age (mean, 43.7 years). Of them, 38 were treated through the SP approach and 30 through the IP approach. The 2 groups were compared in terms of surgery-related indexes, The Hospital for Special Surgery (HSS) knee function score and Johner-Wruhs evaluation for clinical efficacy at 1, 3, 6, and 9 months postoperation. The 2 groups showed no significant differences regarding preoperative general data (P>0.05). Results The 68 patients obtained an average follow-up of 6 months (range, from 1 to 9 months). Intra-operative accumulative fluoroscopy time in the IP group (2.1±1.1 s) was significantly less than in the SP group (3.3±1.8 s) (P<0.05). The number of limited open reduction (1) , intra-operative bleeding volume (128.6±164.1 mL) and number of second intra-operative shifting (4) in the SP group were significantly smaller than in the IP group (7, 216.2±195.9 mL and 10, respectively) (P<0.05). The HSS score in the SP group at 9 months (80.8±7.5 points) was significantly higher than in the IP group (74.0±5.4 points) (P<0.05). The clinical good to excellent rate at 9 months for the SP group (97.4%) was significantly higher than for the IP group (70.0%) (P<0.05). There were also significant differences between the 2 groups in postoperative adverse events like knee pain (P<0.05). No wound infection, limb shortening, internal fixation loosening or rupture, fracture nonunion or mal-union happened in either of the 2 groups. Conclusions In the treatment of tibial shaft fractures with intramedullary nailing, the supra-patellar surgical approach may effectively reduce the incidence of postoperative knee pain so that it can prevent degenerative changes of the knee joint in the long term. It may also lower the incidence of intraoperative second shifting. It also has the advantages of limited incision, simplicity, and limited scaring. In short, it may be superior to the classical infra-patellar approach. Key words: Tibial fractures; Knee joint; Treatment outcome; Infra-patellar approach; Supra-patellar approach

Suprapatellar nailing of tibial fractures–Indications and technique

Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment.The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.

Suprapatellar approach to tibial medullary nailing with electromagnetic field-guided distal locking

Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis.By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20°, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised.The use of the electromagnetic guidance system SureShot® generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.

Radiologic Outcome and Patient-Reported Function After Intramedullary Nailing

The purpose of this study was to compare the patient-reported functional outcomes after intramedullary nailing of the tibia through a retropatellar or infrapatellar approach. Radiographic assessment of nail entry point and accuracy of fracture reduction were included to aid in the identification of variables that may explain any difference in patient-reported outcomes. A retrospective radiographic and questionnaire-based assessment of patient-reported outcomes and complications after tibial nailing for trauma or limb reconstruction through a retropatellar or infrapatellar approach. Regional limb reconstruction unit within a university teaching hospital. Two consecutive series of 38 patients with intramedullary tibial nails inserted through a retropatellar approach, and 36 patients with a tibial nail inserted through an infrapatellar approach. Tibial nail insertion through either a retropatellar or infrapatellar approach. Patient-reported outcomes and complication rates and radiographic assessment of fracture reduction and nail insertion entry point. No significant difference was seen in Kujala score as a measure of anterior knee pain (P = 0.217), either in the physical (P = 0.372) or mental (0.504) components of the SF-12 between the groups, although there was a trend toward symptomatic intrusive knee pain in the infrapatellar group. A more accurate fracture reduction, both in terms of angulation (P = 0.003) and translation (P = 0.010) in the coronal plane, was seen in the retropatellar group. The entry point for nail insertion was more accurate in both the sagittal (P = 0.011) and coronal (P = 0.014) planes. Retropatellar tibial nail insertion is not associated with more anterior knee pain when compared with infrapatellar nail insertion but is associated with more accurate nail insertion and fracture reduction. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

膝半月板および十字靭帯損傷のＭＲＩ診断

We examined 83 patients who had undergone both MRI and arthroscopy. The respective sensitivities, specificities, and accuracies of MRI of the knee were 94.6%, 76.1%, and 85.5% for medial meniscal tears, 80.0%, 82.8%, and 84.3% for lateral meniscal tears, 100%, 97.1%, and 97.6% for anterior cruciate ligament injuries, and 100%, 98.7%, and 98.8% for posterior cruciate ligament injuries. The reasons for inconsistencies between MRI and arthroscopic findings were suggested as follows; 1) a time lag between MRI and arthroscopy, 2) possibilites of lateral meniscal injuries in lateral infrapatellar approach, 3) variability of meniscal tears near the capsule, 4) difficulty of diagnosis of lateral meniscal tears at the posterior forms near the hiatus popliteus tendon.