Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures.

Tibial shaft fractures are common, often arise from highenergy trauma, and may be accompanied by soft-tissue injuries. Static, locked intramedullary nailing is one common approach that works well for many patients with these injuries. The conventional approach to tibial nailing involves an infrapatellar starting point, obtained with the knee in a flexed position, but it can result in anterior knee pain [1, 23, 28]. There have been multiple suggestions as to the etiology, including the position of the nail tip and angle of insertion [12, 15]. In addition, with certain fracture patterns such as proximal tibia fractures, a flexed position of the knee to obtain the starting point was felt to contribute to apex anterior deformity. Although approaches to minimize apex anterior and possible valgus deformities in proximal tibia fractures have been described, including mini-fragment plating, nailing in a semiextended position, and the judicious use of blocking screws [10, 17, 19, 30, 35], some surgeons felt these techniques alone were not sufficient for easy insertion of intramedullary nails in proximal tibia fractures. An alternative to the conventional approach is suprapatellar nailing [15]. It is performed in a semi-extended position, which was believed to improve fracture alignment not only of proximal fractures, but also of more-distal injuries [1]. With a special insertion sleeve, this approach involves an incision through the quadriceps tendon, using a cannula device over a trocar and a protective sleeve to help protect the tendon during nail insertion [7]. Proponents of this technique have suggested it decreases knee pain, improves fracture alignment, and makes it easier to obtain fluoroscopic images [6, 8-11, 16, 20, 32, 37]. But others have raised concerns, including the possibility of cartilage injury to the knee and difficulty removing the nail, should a patient want it removed [22, 37]. This topic is controversial. It’s also important, given the great frequency and potential morbidity of tibial shaft fractures. To help us sort through this, I’ve invited two international experts to debate the topic. Hassan R. Mir MD is the Director of Orthopaedic Trauma Research and the Orthopaedic Program Director at Tampa General Hospital in Florida. He has used this technique for several years and has published on it. Also joining us is Stephan A. Kottmeier MD, Professor andChief ofOrthopaedic Trauma at Stony Brook University in New York. He is known for his thoughtful insight into fracture care and supporting techniques in the care of injured patients. Lisa K. Cannada MD: The key purported benefit of suprapatellar nailing is decreased knee pain, but one large study [19] found no differences between treatment groups among patients followed for at least a year. In Dr. Mir’s article [5], he also comments on the need for “mastery” of a new technique, as well as the need for A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research another installment of Clinical Faceoff, a regular feature. This section is a point-counterpoint discussion between recognized experts in their fields on a controversial topic. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The authors certify that neither they, nor any members of their immediate families, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. L. K. Cannada (✉), Novant Health Orthopedics and Sports Medicine Institute 1901 Randolph Road Charlotte, NC 28207, USA, Email: cannada.lisa@gmail.com