tibial spear fractures are a relatively coarse injury and contemporary treatment includes on-axis arrested development with a lock intramedullary complete in the majority of cases. The conventional technique is via an infrapatellar approach but presently there is a swerve towards the consumption of a suprapatellar approach. We compared cardinal variables including surgical time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nail down in our unit of measurement versus our former know of infrapatellar tibial pinpoint .


twenty-eight consecutive patients with tibial fracture undergo tibial nail via the suprapatellar ( SPN ) approach. Six patients in the study group were excluded due polytrauma and motivation for double orthopedic and fictile operating room management. We compared outcomes with our most late 20 straight patients who had undergo tibial complete via an infrapatellar ( IPN ) approach. chief surgical outcomes were : private detective time, radiation sickness exposure and accuracy of introduction point of the pinpoint on both anteroposterior and lateral radiogram. clinical outcomes included clock time to weightbearing, clock time to radiographic union and patient-reported consequence score ( Lysholm mark ) .


forty-eight straight patients undergo intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study ( 22 SPN vanadium 20 IPN ). There were no meaning differences in affected role demographics or injury patterns between the two groups. running time and radiation exposure were significantly lower in the SPN group when compared to the IPN group ( 115 minute volt 139 min ± 12.5 ) ( 36 cGY/cm2 vanadium 76.33 cGY/cm2 +/- 20.1 ). Furthermore, patients in the SPN group reported lake superior consequence scores at a mean follow up of 3 months ( 8–24 weeks ) There were no ascertained differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months.


Our study shows that borrowing of the SPN approach requires minimal learning bend, and has the electric potential benefits of reduce surgical time, radiation exposure and superior affected role reported outcomes when compared to the ceremonious infrapatellar approach. Keywords:

Trauma, Tibial nail, Tibial fractures, Suprapatellar nail, Approach, Intramedullary nailing

1. Introduction

tibial shaft fractures are common representing 2 % of the workload for all fractures in adults. 1 contemporaneous treatment includes an on-axis fixation with a lock intramedullary nail. traditionally, an infrapatellar approach has been used for this operation however, a suprapatellar approach with the knee in a semi-extended put is gaining popularity due to its benefits, including easier fracture reduction, accurate nail entry point, a short operate on fourth dimension and a lower radiation venereal disease vulnerability. 2, 3, 4 As a department we have adopted the suprapatellar approach for tibial nail down and wanted to compare this to our previous experience using the infrapatellar overture. Accurate pinpoint entrance point will allow the tibial pinpoint to be inserted within an anatomical reference safe partition or “ sweetspot ” as described by Tornetta et aluminum. in cadaverous studies located 5 millimeter lateral to the midplane of the tibial tableland 5 and immediately adjacent and anterior to the articular margin of median tibial tableland. 6 Aiming for an accurate collar entry point will besides help in the fracture reduction by reducing iatrogenic varus and valgus alliance via excessive lateral pass or median entrance points. 7 Fluoroscopy plays an necessity role in fracture reduction and helps with ensuring precise put of the intramedullary nail, however, excessive use of radiotherapy in the operate theater can lead to meaning biological consequences to the surrounding affected role and staff, therefore reducing the radiation acid and prison term exposure is encouraged as good practice. 8, 9 We aimed to achieve the above by adopting this new surgical approach to tibial smash and the aim of this paper is to offer a comparison of surgical and clinical outcomes between the two approaches .

2. Methods

Our study includes 42 straight intramedullary tibial pinpoint fixations performed at our central London Teaching Hospital and Trauma Unit. We included all pornographic ( 18 years and older ) tibial spear fractures for intramedullary pinpoint. exception criteria included polytrauma and/or combined plastic surgery management, former tibial operation, deformity or pathology such as metastatic disease. All back-to-back patients in the study period of 18 months undergo SPN intramedullary collar ( 22 patients ) and these were compared with our most recently performed IPN intramedullary tibial breeze through cases ( 20 patients ). The fracture pattern, classified using the AO classification 10 for tibial diaphyseal fractures, was recorded from imaging and running notes. affected role demographics were recorded from entree paper notes and electronic records. All operations were performed by consultants or senior trainees ( ST7 or above ) on a planned day time Consultant supervised trauma list. The implants used were the DePuy Synthes Expert Tibial Nail and in the suprapatellar cases the DePuy Synthes Suprapatellar Instrumentation for Expert Tibial Nail was used ( DePuy Synthes, Warsaw, IN., USA ). In all cases the surgical standard was general and local anesthetic. At time of initiation all patients received antibiotic prophylaxis. Patients were positioned supine on a radiolucent operating board ; a side support and branch holder were used for the infrapatellar approach setup and a foam wedge in a semi-extended peg situation was used for the suprapatellar approach. Intraoperative time including the initial aligning and fracture decrease were recorded individually for both techniques. radiotherapy time and dose exposure were recorded using a PACS system composition generated by the effigy intensifier intraoperatively. Radiation dose data were measured as Dose Area Product ( DAP ), defined as the venereal disease of radiation absorbed multiplied by the area irradiated the unit of measurement measurements for DAP is expressed as Grey per centimeter squared ( GYcm2 ). 11 The nail submission point was besides assessed for both groups using intraoperative and/or immediate post-operative radiogram. The measurements were assessed on both the anteroposterior and lateral see. The optimum collar submission point was selected as 2 millimeter medial to the lateral tibial spine on the anteroposterior view. On the lateral pass view, the entrance point used was immediately adjacent to and anterior to the articular allowance of the medial tibial tableland reproducible with previous literature descriptions. 12 In non-calibrated radiogram we used the core diameter of the proximal lock screw as a 5 millimeter address degree for the measurements. The pinpoint entrance point was measured for both groups by a blinded perceiver and compared to the optimum introduction point images with measurements saved and reviewed by a second observer. All results were capable to statistical analysis using the Shapiro Wilk test for sample characteristics and a P-value of < 0.05 was considered significant throughout the survey. Patients were contacted postoperatively and asked to complete a stifle trauma particular result score ( Lysholm score ) 13

3. Results

A total of 48 operations were identified over the choose clock period, 6 cases were excluded due to being multiple injuries or having plastics engagement. The infrapatellar nail group ( IPN ) comprised 20 patients with a beggarly age of 32 years ( 28–80 years ). The suprapatellar collar group ( SPN ) comprised 22 patients with a average age of 38 years ( 26–78 years ). The majority of patients had tibial nail down fixation for acute trauma 97.5 % ( 41 ) while 2.5 % ( 1 ) had tibial complete for non-union. There was no significant difference between the IPN and SPN groups for age, sex and open versus closed wound ( ). however, on revue, we noted an attendant finding that fracture patterns were more complex in the SPN group ( ). The most park modes of injury were : fall from a altitude 52 % ( 19 ) and sports injury 25 % ( 9 ). The majority of patients were american Society of Anaesthesiologists ( ASA ) grade 1 ( 96 % ) .

Table 1

Infrapatellar Group Suprapatellar Group P Value
Median age (yrs) 32 (19–76) 38 (22–65) 0.003
Male: Female ratio 10:6 16:4 0.342
Closed fracture: open 14:2 17:3 0.001

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Table 2

Fracture Pattern Simple Wedge Complex
IPN 10 4 6
SPN 4 8 10

Open in a separate window There was a statistically significant difference between the two groups for both total secret agent time and radiation dose exposure. The mean operative meter in the IPN group was 139 ( ±24.5 ) minutes compared to 110 ( ±34.2 ) minutes for the SPN group ( p < 0.05 ). The IPN group had a mean radiotherapy venereal disease ( Dose Area Product ) of 76.33 ( ±33.4 ) cGY cm2 compared to 36 ( ±28.6 ) cGY cm2 for the SPN group ( phosphorus < 0.05 ) ( ). Comparing the nail submission point between the two groups we observed a superscript accuracy of pinpoint entry point relative to the trace ideal point of entry using the SPN set about. In the IPN group the base entrance point on the AP radiogram was±3.5 millimeter ( ±1.8 millimeter ) while in the SPN group on AP radiogram was±2.1 millimeter ( ±0.9 millimeter ) ( P < 0.01 ) from the entrance point. similarly, on the lateral radiogram the mean introduction point was±7.6 millimeter ( ±2.1 millimeter ) and +-5.2 millimeter ( ±1.6 millimeter ) ( P < 0.04 ) from the entrance point for IPN and SPN respectively (, ).

Table 3

Outcome (Mean) IPN SPN
Operative Time 139 110
Radiation dose (cGY/cm2) 76.3 46.5
Lysholm score 75 90

Open in a separate windowFig. 1Open in a separate windowFig. 2Open in a separate window At outpatient clinical follow up all patients were asked to complete a Lysholm grudge questionnaire with a focus on front tooth stifle pain and return to normal routine degree. The SPN showed superior results compared to the IPN group at think of follow up duration of 6 weeks despite the SPN group having more building complex fracture patterns. The mean Lysholm score was 90 ( 84–100 ) in the SPN group compared to 75 ( 62–95 ) to the IPN group .

4. Discussion

Our study suggests improved collar entry-point, reduced operative time and radiation exposure and higher patient satisfaction scores in the early post-operative period may be achieved with SPN versus IPN tibial nail. The SPN approach makes designation of the ideal entrance decimal point easier ascribable to the advantageous human body of the trochlear notch of the femur acting as a stabilizing scout. We found nail entrance detail in the SPN approach was more accurate on both AP and lateral pass radiogram which is consistent with a similar report by Jones et alabama. 14 The importance of a more accurate pinpoint submission point is demonstrated by better fracture decrease and less risk of wrong to the intra-articular airfoil therefore leading to reduced trouble, better officiate and electric potential to minimise post-traumatic osteoarthritis. In our analyze we have focused on the authoritative effect of the SPN border on on the radiation time and vulnerability which may be due to the mesa frame-up with the stifle in a semi-extended position. This more accurate nail down entry point gives the C-arm of the prototype intensifier better access to the limb intra-operatively, frankincense fewer radiographs are required to check breeze through put and alimony of fracture reduction, ampere well as this reducing the time between anteroposterior and lateral radiogram without the need for limb reposition. 15 On the reverse the IPN overture, due to the use of blocks and the indigence to change limb position between radiogram for unlike views increases the count of radiogram taken in order to obtain proper images therefore increasing radiation time and exposure. The radiation sickness exposure is crucial for both patients and staff. Despite wearing tip protection, even engage in injury theatres will undoubtedly lead to extra radiation sickness exposure and frankincense being able to minimise this is desirable. Two previous studies compared radiation sickness time and vulnerability between the two techniques. Sun et alabama. demonstrated that radiotherapy clock time was reduced in the SPN compared to IPN approach in 162 tibial nails 16 and another supporting study by Williamson et al., who besides compared radiation time and exposure between the two techniques in 90 tibial nails 17 besides demonstrated this. however, in the first gear analyze didn ’ thymine expect at the radiation dose and the late study compared entirely the fluoroscopy difference between the two techniques unlike our study where we compared multiple factors. furthermore, due to the fact that this is a raw technique there may be some concerns over the effect of the learning crook on outcomes such as radiation sickness exposure ( DAP ) and fluoroscopy meter while surgeons learn this proficiency. however, this has been studied by Valsamis et alabama. 18 and they demonstrated that in the hands of experience trauma surgeons there is no significant impact of the learning curve and thus no increased radiation dose photograph as compared to the more traditional technique of the Infrapatellar tibial nail access. Anterior knee pain is one of the most common presentations following tibial pinpoint insertion as described in the literature. 19 The consequence of anterior stifle pain in our study was assessed using a validated patient questionnaire, the Lysholm scale. 13 This specifically asks about anterior knee pain, pain on squat, pain on climbing the stairs and whether a walk joint is required, any swelling and locking ace. This attributes a score depending on answers where > 90 is good and < 65 is inadequate. In our study fewer patients reported anterior stifle pain in the SPN group compared to the IPN group which may be due to the accuracy of the femoral trocar security sleeve which helps with the aligning of the usher electrify, reducing iatrogenic soft tissue trauma or could be a by-product of a aloof entry incision from the proximal tibia, this is reproducible with findings from a survey by Courtney et aluminum. who reasoned that during the SPN approach the infrapatellar steel is distant from the incision compared to the IPN. 20 A far meta-analysis by Xu et aluminum. supports our finding of lower incidence of anterior knee pain following SPN tibial pinpoint. 21 however, it is crucial to bear in heed that this new approach path is not free from complications. A late sketch evaluated 139 receptive tibial shaft fractures which were managed by an SPN set about 22 and demonstrated, in a individual case, that septic arthritis of the knee joint may occur following SPN tibial complete. Longer term sequela of SPN tibial complete have been an ongoing concern and well discussed in the literature. versatile studies have compared intra-articular injuries between the two techniques 23 looking at secondary coil iatrogenic damage to the cartilage surface of the patellofemoral joint or other intra-articular structures such as the footprint of the anterior cruciate ligament, the meniscus and the intermeniscal ligament. 24 While we acknowledge this concern, as demonstrated by Tornetta et alabama. on cadaverous knees, this can be avoided by following simpleton steps to aim for the ‘ safe zone ’ in the breeze through entrance point which, as described above, is slenderly lateral to the center of the tibial tuberosity 5 and by using the specifically designed silicone protection sleeve which is a standard part of the SPN instruments. indeed, Leary et aluminum. found there is no evidence of wrong to the knee structures on both insertion and extraction of the suprapatellar tibial nail down in a cadaverous stifle study using a standard SPN technique and instruments. 25 further testify comes from a survey to assess for chondral damage by Gelbke et aluminum. 26 They demonstrated that following SPN tibial breeze through there was not only no increase in the macroscopic chondral damage compared with IPN tibial complete but that the increased intra-articualr pressure generated was well below the threshold to cause chondrocyte death at a microscopic level. We acknowledge some limitations of our study. This is a age group analyze design utilised to establish initial outcomes with use of this modern approach in our department. We found a wide variation in patient reported consequence scores at follow-up and had a relatively little sample size therefore we acknowledge greater margins for error in interpreting clinical outcomes specifically. duration of adopt up was limited to 4 months and consequently longer-term benefits or risks have not been reported in this study. We believe 4 months is a satisfactory, hardheaded time period for typical follow up after routine, uncomplicated tibial collar. Our outcomes are based on clinical examination and affected role ’ south atonement scores, possibly a more objective method to assess heal and damaged articular surface would add validity to our survey for exemplar post-operative knee arthroscopy or MRI read .

5. Conclusion

In our sketch, adoption of the SPN approach path reduced operative time and radiation exposure and achieved greater accuracy of collar entry indicate compared to IPN approach. clinical follow up of patients demonstrated higher affected role satisfaction scores after SPN tibial nail down when compared to the conventional approach with no change in complication rate at four months follow-up. Our findings have led to the adoption of the SPN border on as standard for tibial complete in our trauma whole.

In the current climate of COVID-19 minimising secret agent clock and exposure is peculiarly significant in order to provide condom, effective trauma care for both patients and staff. We recommend farther prospective randomised controlled trials comparing techniques to far evaluate the transcendence of the SPN tibial nailing versus IPN tibial breeze through .

Contributor statement

MA, DD ; data collection, analysis, manuscript cooking, submission and revision, ZS, RK ; manuscript preparation, AA ; data collection, analysis, manuscript formulation .

Declaration of competing interest

none .

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