The Parapatellar Approach to Intramedullary Tibial Nailing
Condition: Knee Pain Intermittent
Study type: Observational

Summary: 
      This project will address the incidence of anterior knee pain in the approaches used for
      tibial nailing. A parapatellar approach, with nail insertion in relative extension, will be
      compared to the approaches in which nail insertion requires the knee to be placed in flexion.
      The incidence of anterior knee pain will be compared in each group to assess whether the
      compared approaches result in similar levels of anterior knee pain. Patients will be given
      the 2000 IKDC Subjective Knee Evaluation Form to assess anterior knee pain. The 2000 IKDC
      Subjective Knee Evaluation Form is a newer assessment tool created by the International Knee
      Documentation Committee. It has been validated for use with broad patient populations dealing
      with various knee disorders.19
    

Detailed description: 
      In the population affected by orthopaedic injury, fractures of the tibial shaft are the most
      common of all long bone fractures. This fracture pattern occurs approximately 26 times per
      100,000 people and accounts for 77,000 hospitalizations per annum.(1, 2) Intramedullary
      nailing is the most common operative treatment choice for fractures of the diaphyseal tibia
      (tibial shaft). Intramedullary nailing is also commonly used for shaft fractures that extend
      into the metaphyses (excluding fractures that extend into the knee and/or exhibit comminution
      at the ankle joint).

      Tibial nails are inserted at or about the knee. Three different insertion approaches are used
      as standard of care at this institution, including the transtendinous, peritendinous, and
      parapatellar approach. In all three techniques, the nail is placed in the tibia in the same
      manner: after fracture reduction, the proper entry point in the proximal tibia is found and
      the tibia is sequentially reamed until a suitable nail can be passed and locked in place with
      interlocking screws. The three named approaches vary the (1) angulation of the knee at the
      time of insertion and the (2) location of the incision and soft tissue dissection, relative
      to the patellar tendon, necessary to locate the proper entry point for the nail. Tibial nails
      are inserted with the knee in flexion (bent to ~90°) for the transtendinous and peritendinous
      approaches, and in relative extension (less than 30°) for the parapatellar approach. For
      insertion, the transtendinous and peritendinous approaches require dissections that allow the
      nail to be passed through or around the patellar tendon. In the parapatellar technique,
      dissection is carried out juxtaposed to the patella.

      Anterior knee pain is the most common complication of intramedullary tibial nailing. It has
      been reported in a range of 10% to 86% with average follow up of two years.(3) Review of
      current literature regarding the subject of anterior knee pain and tibial nailing reveals
      four commonly attributable causes: skin incision location,(4,5) approach in reference to the
      patellar tendon,(6-9) nail insertion site,(10) and nail prominence.(11-13) No study has
      specifically examined whether knee angulation at the time of insertion impacts anterior knee
      pain.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Patients will be indicated for intramedullary tibial nailing according to their fracture
        pattern.
      
Keywords: Knee pain; tibial nailing