Suprapatellar Approach Research Articles

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.

A Heart-shaped Sleeve Simplifies Intramedullary Tibial Nail Insertion when Using the Suprapatellar Approach.

The suprapatellar approach for intramedullary tibial nailing has become widely accepted over the past decade. A round sleeve is passed beneath the patella to protect the surface of the patellofemoral joint (PFJ). However, the round sleeve cannot be easily stabilized in the PFJ because it does not conform to the shape of the patellar apex. Consequently, we produced a heart-shaped sleeve to simplify the insertion of the entry sleeve during the suprapatellar approach. Using the new sleeve, the following procedure is used: (1) make a longitudinal 4 cm skin incision proximal to the patella to reach the PFJ, (2) insert the guide pin manually to the ventral edge of the tibial plateau, (3) insert the cannulated trocar along the guide pin, (4) insert the heart-shaped sleeve along the cannulated trocar, (5) remove the cannulated trocar, (6) ream the entry point through the heart-shaped sleeve. Then, continue insertion of the nail in the standard manner. Among 44 patients (29 men, mean age 45.6 years, range 26-87 years) with tibial fractures treated between 2010 and 2015, the first 18 consecutive cases were performed using a round sleeve and the rest were performed using the heart-shaped sleeve. The surgery time until entry reaming commenced was 8.9 min (range 6-12 min) using the round sleeve and 6.2 min (range 3-12 min) using the heart-shaped sleeve (P < 0.05). The heart-shaped sleeve is easily stabilized in the PFJ and greatly simplifies the intramedullary nailing of tibial shaft fractures using the suprapatellar approach.

In-Plane Ultrasound-Guided Knee Injection Through a Lateral Suprapatellar Approach: A Safe Technique.

This study aims to describe a technique for in-plane ultrasound-guided knee arthrography through a lateral suprapatellar approach, reporting its accuracy and related complications. A retrospective search was performed for computed tomography and magnetic resonance reports from June 2013 through June 2015. Imaging studies, puncture descriptions, and guided-procedure images were reviewed along with clinical and surgical history. A fellowship-trained musculoskeletal radiologist performed all procedures under sterile technique and ultrasound guidance with the probe in oblique position on the lateral suprapatellar recess after local anesthesia with the patient on dorsal decubitus, hip in neutral rotation, and 30 to 45 degrees of knee flexion. A total of 86 consecutive subjects were evaluated (mean, 55 years). All subjects underwent intra-articular injection of contrast, which was successfully reached in the first attempt in 94.2% of the procedures (81/86), and in the second attempt in 5.8% (5/86) after needle repositioning without a second puncture. There were no postprocedural reports of regional complications at the puncture site, such as significant pain, bleeding, or vascular lesions. Our study demonstrates that in-plane ultrasound-guided injection of the knee in semiflexion approaching the lateral suprapatellar recess is a safe and useful technique to administer intra-articular contrast solution, as an alternative method without radiation exposure.

Intramedullary Nailing with a Suprapatellar Approach and Condylar Bolts for the Treatment of Bicondylar Fractures of the Tibial Plateau.

Background:Bicondylar tibial plateau fractures have been treated with either plating or external fixation techniques, with conflicting results. A recently introduced technique involving the combined use of intramedullary nailing via a suprapatellar approach and condylar bolts could represent a new pathway toward better treatment of this severe injury.Methods:The present report describes a retrospective and prospective study of all 17 patients (age range, 25 to 75 years) who were admitted under the author’s care for the treatment of a closed, bicondylar tibial plateau fracture between 2013 and 2015. All patients consented to undergo fixation of the fracture with intramedullary nailing through a suprapatellar approach and with use of condylar bolts. The reconstructed articular surface was supported with freeze-dried allograft that had been previously soaked in concentrated bone marrow. The patients were followed at regular intervals, and the results were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS).Results:All patients were followed for at least 1 year (average and standard deviation, 25.23 ± 8.95 months; range, 12 to 46 months). All fractures united clinically and radiographically between 10 and 22 weeks (average, 15.1 ± 2.91 weeks), with no instances of neurovascular complication, infection, or implant failure. One patient underwent early revision of the fixation because of unsatisfactory reduction of the articular surface, and 1 patient had secondary fracture displacement. One condylar bolt was removed after fracture healing because of irritation at the insertion site. However, all patients regained knee motion without physiotherapy and all were fully weight-bearing by the fifth postoperative month.Conclusions:The short and intermediate-term results associated with the use of the proposed technique appear to be satisfactory. However, the effectiveness of the technique should be reassessed with long-term studies as well as comparative studies involving other fixation techniques.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: Evaluation of the patellofemoral joint

Intramedullary nail fixation is a common treatment for tibial-shaft fractures, and it offers a better functional prognosis than other conservative treatments. Currently, the primary approach employed during intramedullary nail insertion is the semiextended position is the suprapatellar approach, which involves a vertical incision of the quadriceps tendon Damage to the patellofemoral joint cartilage has been highlighted as a drawback associated with this approach. To avoid this issue, we perform surgery using the patellar eversion technique and a soft sleeve. This method allows the articular surface to be monitored during intramedullary nail insertion. We arthroscopically assessed the effect of this technique on patellofemoral joint cartilage. The patellar eversion technique allows a direct view and protection of the patellofemoral joint without affecting the patella. Thus, damage to the patellofemoral joint cartilage can be avoided.

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

IntroductionTraditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine − STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures. MethodologyA case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing. ResultsThere was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p=0.007, 130.3min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control]. ConclusionIntraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.

Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study

Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches. Materials and methodsPaired legs from 10 fresh frozen cadavers were used. An arthroscopy was performed in each knee, documenting the status of the knee prior to the insertion of the tibia nail. In a random manner, the left or right leg underwent nailing with a suprapatellar or parapatellar approach in a semi-extended position. Fluoroscopy was utilized in each case to localize the entry point, and a tibia nail was inserted in all cases. A knee arthrotomy was then performed and the status of the following structures was assessed: patella and trochlea cartilage, tibia plateau cartilage, inter-meniscal ligament, lateral and medial meniscus, and the ACL. ResultsThe correct fluoroscopy entry point was achieved in all of the specimens (20). Three legs (3/10) with parapatellar approach had intra-articular disruption. In legs with a suprapatellar approach, patellar cartilage and trochlea cartilage damage was found in two of the specimens, respectively. There was one specimen with cartilage damage in the parapatellar approach. There were no meniscal injuries. Partial laceration of the intermeniscal ligament was found in three of the knees for each approach. One ACL injury was found in the suprapatellar group. Mean distance from the entry point to major structures is not significantly different with either approach. (p=0.45). ConclusionsA good fluoroscopic entry point can be achieved using either the parapatellar or suprapatellar approach. The parapatellar approach for tibia nailing has similar rate of soft tissue damage compared to the suprapatellar approach. The suprapatellar approach damaged the cartilage in one-third of the cases and if cartilage injury occurs with the parapatellar approach, this is located in a low risk area.

Locked META intramedullary nailing fixation for tibial fractures via a suprapatellar approach.

Background:Intramedullary nailing is an effective approach for treatment of diaphyseal tibial fractures. However, infrapatellar intramedullary nailing can easily cause angulation and rotation displacement at the fracture ends and increase risk of postoperative infection. Intramedullary nailing via the suprapatellar approach was proved with good reduction and fixation. We used locked intramedullary nailing for the treatment of tibial fractures via a suprapatellar approach in this study.Materials and Methods:23 patients undergoing tibial fractures fixation by locked META intramedullary nailing via a suprapatellar approach were enrolled between June 2012 and October 2013. There were 18 males and 5 females. The average age was 35.5 years (range 18-60 years). The intraoperative data including operative time and blood loss and postoperative data consisting of hospital stays, fluoroscopy time, fracture healing time and complications were all recorded.Results:The average operative time, blood loss, fluoroscopy time and hospital stay were 78.2 ± 9.1 min, 90.4 ± 23.4 mL, 38.5 ± 6.5 s and 11 ± 3.4 days respectively. The mean followup period in all the patients was 15.5 months. Callus appeared in the patients at average 8 weeks after surgery. The mean knee and ankle range of motion were significantly improved at the last followup (P < 0.05). The average Hospital for Special Surgery and Olerud–Molander scores was 92 ± 4.3 points and 93.6 ± 3.9 points, respectively. No complications were observed.Conclusion:Locked META intramedullary nail fixation via a suprapatellar approach is safe and effective for patients suffering from tibial fractures and earlier functional recovery.

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.

Intramedullary nailing in proximal third tibial fractures

Intramedullary nailing is the gold standard in the treatment of shaft tibial fractures. When in the past proximal tibial fractures had to be treated by nailing, it became difficult to control the large metaphyseal fragment, which led to a high risk of malalignment, iatrogenic fractures and anterior knee pain. The reduction forceps and “poller screw” techniques are useful to control the fracture site. In our experience, we started to practice tibial intramedullary nailing through a suprapatellar approach, in order to try a more proximal entry point and obtain a good alignment with the tibial axis. In our institute we also treated proximal tibial fractures involving the articular surface using nailing through a suprapatellar approach. The first step involved reduction of the articular fracture line using lag cannulated screws; after percutaneous osteosynthesis, we practiced an intramedullary nailing in the semi-extended knee position.

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.

Inchiodamento tibiale con accesso sovrarotuleo mininvasivo

Intramedullary nailing is the “gold standard” in the treatment of shaft tibial fractures. It provides high rates of bone healing. We analyzed the advantages of intramedullary nailing using a suprapatellar approach, which reduces the risk of DVT and makes patient management in the operating room easier.

Estudo anatômico da via de acesso suprapatelar lateral para a haste intramedular bloqueada na fratura da tíbia

OBJECTIVE: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. METHODS: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. RESULTS: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. CONCLUSION: There is a need to develop specific material to minimize injury to intra-articular structures when using this route.

ANATOMICAL STUDY ON THE LATERAL SUPRAPATELLAR ACCESS ROUTE FOR LOCKED INTRAMEDULLARY NAILS IN TIBIAL FRACTURES

Objective: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. Methods: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. Results: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. Conclusion: There is a need to develop specific material to minimize injury to intra-articular structures when using this route.

The suprapatellar approach in intramedullary tibial nailing

The suprapatellar approach in intramedullary tibial nailing

Intramedullary Nailing of Tibial Fractures: Review of Surgical Techniques and Description of a Percutaneous Lateral Suprapatellar Approach

The lateral percutaneous suprapatellar approach in a semi-extended position is an excellent approach for intramedullary nailing of tibia fractures.

Electrosurgical Arthroscopic Patellar Denervation

Patellofemoral pain depends on many pathophysiologic factors and may be difficult to manage. It often occurs with no apparent cause in young persons. A new arthroscopic technique based on anatomic and pathophysiologic studies is described here for the treatment of patients with patellofemoral pain and no or minimal malalignment. Nociceptive receptors are richly distributed in the peripatellar soft tissue. We surmised that a thermal lesion to this region would lead to desensitization of the anterior knee area, referred to as patellar denervation. With the leg in maximum extension, the electrocoagulator is inserted through a combined anterointernal and suprapatellar approach to access the entire perimeter of the patella. A simple thermal lesion to the peripatellar soft tissue in the region closest to the patella is enough to obliterate a considerable number of nociceptive receptors. This thermal lesion should not include the region of the patellar tendon because this is an important site of entry for vessels reaching the patella, and injury to these vessels may cause patellar necrosis. Patellar denervation achieved through this simple technique may offer a solution for patients with intractable patellofemoral pain with no evident alterations.