Avascular necrosis predictive factors after closed reduction in patients with developmental dysplasia of the hip.

Background: Developmental dysplasia of the hip (DDH) is a common pediatric orthopedic condition. Closed reduction (CR) is the conservative treatment approach with high success rates for DDH. However, avascular necrosis (AVN) is a severe potential complication after this procedure. This study retrospectively assessed the potential risk factors for AVN occurrence after CR and Spica cast immobilization. Materials and Methods: In a retrospective observational study, 71 patients (89 hips) with DDH aged 6-24 months old undergoing CR were enrolled. All patients were followed up for 3 years, and their demographic data, initial Tönnis grade, pre-reduction procedures, abduction angle in the Spica cast, and the AVN presence (based on Bucholz and Ogden classification [3rd-4th class]) were documented. Results: Of 71 patients (89 hips) with a mean age of 12.5 ± 3.9 months, 13 patients (18 hips) developed AVN. The mean age of patients in the AVN and non-AVN groups was 14.3 ± 4.9 and 12.2 ± 3 months (P = 0.07); also, the mean abduction angle in patients with and without AVN was 51.86 ± 3.66 and 58.46 ± 3.91 (P < 0.001) in univariate analysis. The distribution of initial Tönnis grade, and previous conservative procedures, adductor tenotomies during the CR were comparable between the two groups (P > 0.05). We found age 12 months and 54° in abduction angle as the best cutoff values for differentiating AVN patients from non-AVN and the risk of experiencing AVN for patients older than 12 months was odds ratio (OR) =4.22 (P = 0.06) and patients with abduction angle greater than 54 was OR = 34.88 (P < 0.001). Conclusion: In this study, older age at the time of intervention and larger abduction angle in the hip Spica cast were two predictors of experiencing AVN in DDH patients after undergoing CR treatment approach. Performing CR at a younger age and keeping the abduction angle lower than 54° in the hip Spica cast could help to have the best possible prognosis. Level of Evidence: IV, retrospective, observational, cross-sectional study.

Intramedullary nail versus minimally invasive plate osteosynthesis for displaced extraarticular proximal tibia fractures: a prospective comparative cohort study.

PURPOSE: The treatment of extraarticular proximal tibial fractures is challenging. As the optimal fixation technique is still debated, the purpose of this study was to compare minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation. METHODS: A prospective matched comparative study was conducted on patients with displaced extraarticular proximal tibia fractures treated with MIPO (n = 29) versus IMN (n = 30) fixation. Outcomes collected were the Johner-Wruhs grading, range of motion (ROM), union rate, time to union, malunion, coronal and sagittal alignment, and post-operative complications. RESULTS: Union rates were similar between the MIPO and IMN groups (93% vs. 97%, P = 1.0). The IMN group had an earlier time to union (15 vs. 18 weeks, P < 0.001) and superior functional outcomes at one year (effective Johner-Wruhs score: 80% vs. 55%, P = 0.04). There was a significantly higher incidence of anterior knee pain in the IMN group (23% vs. 0%, P = 0.02) and there was a trend for more infections in the MIPO group (21% vs. 13%, P = 0.73). CONCLUSION: IMN fixation of extraarticular proximal tibia fractures was associated with a shorter union time and better functional scores compared to MIPO.

Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children.

PURPOSE: One of the most widespread diseases of children's orthopaedic problems is flatfoot. If conservative therapy failed, surgical treatment would be indicated. Lateral calcaneal lengthening (LCL) and subtalar arthroereisis (SA) are two types of operations used to correct symptomatic flexible flatfoot (FFF). The purpose of this study is to compare the functional and radiographic features of these two surgical procedures. PATIENTS AND METHODS: In this prospective randomized clinical trial study, we recruited 66 patients between 2018 and 2019. For clinical assessment, American Orthopedics Foot and Ankle Society (AOFAS), visual analog scale (VAS), subtalar motion, presence of medial longitudinal arch, and family satisfaction were measured. Evaluation of radiographic angles was based on AP (AP Tal-1Met) and Lat (Lat Tal-1Met) view of Talus-1st metatarsal angle (Meary's angle) and calcaneal pitch. RESULT: There was no significant difference between the two types of surgery regarding Lat Tal-1Met and AP Tal-1Met. The significantly larger angle in the LCL group was calcaneal pitch (P value < 0.001). AOFAS significantly increased from 68.71 ± 5.70 to 87.87 ± 7.14 (P value < 0.001) and from 67.28 ± 6.01 to 86.14 ± 7.56 (P value < 0.001) in LCL and SA respectively. Family satisfaction was significantly higher in the SA (8.14 ± 0.97) comparing to LCL (7.29 ± 0.86) at the latest follow-up (P value < 0.001). CONCLUSION: While both groups have substantial improvement in clinical and radiographic aspects, the SA technique is less-invasive, rapid symptom relief, and has early weight-bearing capacity. TRIAL REGISTRATION: IRCT20180823040853N1.

Where does magnetic resonance imaging stand in the diagnosis of knee injuries?

BACKGROUND: The aim of this study was to determine the diagnostic value of magnetic resonance imaging (MRI) in the diagnosis of knee injuries. MATERIALS AND METHODS: Ninety-eight consecutive patients were enrolled in the study. In all patients, MRI and arthroscopy were performed and the results were compared. RESULTS: MRI was most sensitive in the detection of medial meniscus injuries, and the highest specificity and negative predictive value (NPV) were found in the detection of posterior cruciate ligament injuries. CONCLUSION: MRI is a valuable tool, and according to its high NPV, normal MRI can prevent unnecessary arthroscopic interventions.

Designing a prognostic scoring system for predicting the outcomes of proximal fifth metatarsal fractures at 20 weeks.

BACKGROUND: Fractures of the proximal fifth metatarsal bone are among the most common fractures observed in the foot and their classification and management has been subject to much discussion and disagreement. In this study, we aim to identify and quantify the effect of possible predictors of the outcome of the treatment of proximal fifth metatarsal fractures. METHODS: Patients with established proximal fifth metatarsal fractures were enrolled in this prospective cohort and the outcome of their treatment was assessed using the AOFAS mid foot scale at 6 and 20 weeks. RESULTS: 143 patients were included in the study. Our study showed that displacement, weight and type III fractures were significant independent predictors of poor outcome at 6 weeks while at 20 weeks in addition to these factors, gender and diabetes mellitus were also shown to be significant independent predictors of poor outcome. A scoring system was designed by assigning weight to these factors and it was shown to be a strong predictor of outcome at 20 weeks. CONCLUSION: We recommend that our scoring system would help surgeons to decide whether patients' prognostic factors are significant enough for him/her to opt for a surgical approach to treatment rather than a conservative approach.

A randomized clinical trial on comparison of corticosteroid injection with or without splinting versus saline injection with or without splinting in patients with lateral epicondylitis.

BACKGROUND: Lateral epicondylitis is a common problem affecting 1-3% of the population. There has been much debate about the best treatment modality for this condition. There is, however, no conclusive evidence in support of any of the proposed treatment modalities. In this trial, we have studied the effect of corticosteroid injection (with or without splinting) with normal saline injection (with or without splinting). MATERIALS AND METHODS: In this double-blind, randomized clinical trial, individuals were randomly assigned to either of four treatment groups and received either 40 mg depomedrol injection alone, 40 mg depomedrol injection with splinting, normal saline injection alone, or normal saline injection with splinting. They were evaluated using the visual analog scale (VAS) at weeks 2, 4 and 24 and with the Oxford elbow scale (OES) at 24 weeks. RESULTS: A total of 79 patients were participated in the study. The corticosteroid injection groups had better pain relief as measured by VAS at 2 and 4 weeks compared with the two saline injection groups. Mean VAS difference at week 0 versus week 2 was 4.5 ± 0.9 and 2.8 ± 0.6 in corticosteroid injection groups and saline injection groups respectively (P < 0.01) but at 24 weeks, there was only moderate benefit reported for the group which received steroid injection and splinting (P < 0.01) compared to the saline injection groups. The saline injection groups reported better improvement in OES scores (20.1 ± 3.7) at the end of the trial compared corticosteroid injection groups (16.1 ± 2.9) (P < 0.05). CONCLUSION: Our results indicate that despite the clear pain reduction benefit associated with steroid injection in short term, this benefit in comparison with normal saline injection fades by the 24(th) week of follow-up.

Evaluation of instability factors in distal radius fractures.

BACKGROUND: Fractures of distal radius are one of the most common fractures seen by physicians and account for 20% of all fractures seen in the emergency room. Various factors contribute in secondary displacement of fracture fragments after anatomic or near anatomic close reduction and cast immobilization in distal radius fractures. This study was designed to examine the correlation between radiographic outcomes in the closed treatment of unstable distal radius fractures and different risk factors. MATERIALS AND METHODS: One hundred and fifty-seven patients were included in this prospective study. There were 107 women and 50 men; with a mean age of 51 ± 16.7 years (range: 20-86 years). During the follow-up in all radiographs, the following variables were analyzed as instability factors: (1) Age, (2) gender, (3) radial shortening, (4) dorsal comminution, (5) articular step-off, (6) radial inclination, (7) associated ulna fracture, and (8) dorsal angulation. RESULTS: Based on the radiographic criteria for an acceptable reduction, 92 patients (58.6%) failed to maintain an acceptable reduction and classified as group I, while in 65 patients (41.4%), the postoperative radiographs were within an acceptable range and classified as group II. The mean age of patients in group I was higher than group II (P < 0.001). Radial shortening of more than 6.5 mm, loss of radial inclination of more than 6.5 degrees, and age above 52 at presentation were the most important predictive factors for instability. CONCLUSION: Among the variables, the most important predictors of redisplacement after an acceptable closed reduction were loss of radial height, loss of radial inclination, and age.

A study on the effect of radiographic angles on clubfoot's recurrence.

Clubfoot is one of the common orthopaedic deformities. However, regardless of its' treatment high success rate, recurrence of the deformity is a serious issue. The aim of this study is to evaluate if radiographic angles can be used for clubfoot recurrence prediction. This is a prospective study on 91 patients (134 feet) with mean age of 9.5 ± 2.3 days and male/female ratio of 2/1 on patients with congenital clubfoot admitted to our hospital. Pre and one-year post-tenotomy tibiocalcaneal (TIC-L), talocalcaneal (TC-L) and calcaneal-first metatarsal angles (C1M-L) in the lateral view of the patients' radiographs, and their recurrence status until three years were measured. Ten feet experienced relapse. The mean pre and one-year follow-up measurements of TC-L, C1M-L, and TIC-L angles were significantly different between patients who experienced relapse and others (P < .05). The cut-off points of 1.75 and 6.5 for one-year follow-up Pirani and Dimeglio scores for recurrence prediction were suggested respectively. Also, cut-off points of 26.5 and 79.5 for one-year follow-up TC-L and TIC-L angles for recurrence prediction were calculated, respectively. We demonstrated that the pre-tenotomy and one-year follow-up TIC-L, TC-L, and C1M-L angles are helpful in clubfoot recurrence prediction after Ponseti treatment.

Plantar fasciitis.

Heel pain, mostly caused by plantar fasciitis (PF), is a common complaint of many patients who requiring professional orthopedic care and are mostly suffering from chronic pain beneath their heels. The present article reviews studies done by preeminent practitioners related to the anatomy of plantar fasciitis and their histo-pathological features, factors associated with PF, clinical features, imaging studies, differential diagnoses, and diverse treatment modalities for treatment of PF, with special emphasis on non-surgical treatment. Anti-inflammatory agents, plantar stretching, and orthosis proved to have highest priority; corticosteroid injection, night splints and extracorporeal shock wave therapy were of next priority, in patients with PF. In patients resistant to the mentioned treatments surgical intervention should be considered.

Can clubfoot scoring systems predict the number of casts and future recurrences in patients undergoing Ponseti method?

BACKGROUND: Congenital clubfoot is one of the common congenital orthopaedic deformities. Pirani and Dimeglio scoring systems are two classification systems for measuring the severity of the clubfoot. However, the relation between the initial amount of each of these scores and the treatment parameters is controversial. METHODS: Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, the number of castings as a short-term treatment parameter, and the recurrences as a long-term parameter until the age of three were prospectively documented. RESULTS: One hundred patients (143 feet) with mean age of 9.51 ± 2.3 days including 68 males and 32 females and the mean initial Pirani score of 5.5 ± 0.5 and the mean initial Dimeglio score of 17.1 ± 1.6 were studied. The incidence of relapse was 8.4 %( n = 12). The mean initial Pirani score (P < 0.001) and the mean initial Dimeglio score (P < 0.003) of the feet with recurrence were significantly more than the non-recurrence feet. The mean number of casts in the recurrence group (7 ± 0.9) was significantly more than the feet without recurrences (6.01 ± 1.04) (P = 0.002). The ROC curve suggested the Pirani score of 5.75 and the Dimeglio score of 17.5 as the cut-off points of these scores for recurrence prediction. CONCLUSION: In our study, Pirani and Dimeglio scores are markedly related with more number of casts and recurrence in patients with severe and very severe clubfoot. Also, we have introduced new cut-off points for both classification systems for prediction of recurrence. To the best of our knowledge, this finding has not been introduced into the English literature.

Correction of the knee coronal plane deformity using the screws plus reconstruction plate versus cannulated screws.

INTRODUCTION: Knee angular deformity is a common finding occurring in the childhood that can cause gait disturbances and early compartment osteoarthritis. Despite various surgical approaches presented to correct the angular deformities of the knee, there is still a search for the best approach. Thus, the present study was conducted to compare the results of using cannulated screw (CS) versus screw plus reconstruction plate (SpRP) for correction of angular deformities through a two-year follow-up study. HYPOTHESIS: Percutaneous CS implantation is as efficacious as SpRP implantation for the correction of angular deformities of the knee. MATERIAL AND METHODS: This randomised clinical trial (RCT) was conducted on 63 patients with angular deformities who were randomly divided into two groups including treatment with cannulated screw (CS) (n=32) and treatment with screw plus reconstruction plate (SpRP) (n=31). All the patients underwent the alignment view radiography of both lower limbs before surgical procedure and then within 3, 6, 12, 18 months and 2 years following the surgery. Afterwards, the patients' mechanical axis of the knees, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and varus/valgus angles were assessed and compared. RESULTS: Results of the study showed that MPTA and LDFA significantly turned to the normal range during the 18 months follow-up in both treatment groups (p-value<0.001). Varus and valgus angles were corrected in both techniques as well postoperatively (p-value<0.001). Ultimate correction was achieved earlier in the CS treated group (12 months versus 18 months later). DISCUSSION: Findings of the study revealed that the percutaneous CS implantation was successful similar to the SpRP implantation for correction of the angular deformity, while earlier ultimate angular correction and less pain complaint were among the superiorities of the CS. LEVEL OF THE STUDY: II, comparative prospective study.

The Role of Fibular Fixation in the Treatment of Combined Distal Tibia and Fibula Fracture: A Randomized, Control Trial.

BACKGROUND: This randomized, parallel-group, non-blinded study was designed to determine the role of fibular fixation in the treatment outcomes of combined distal tibia and fibula fractures. MATERIALS AND METHODS: Sixty patients with distal tibial and fibular fractures were randomly divided in two groups of case and controls. In the case group, fibula was fixed prior to the fixation of tibia. In the control group, tibia was fixed without fibular fixation. Primary outcomes were varus-valgus angulation, anterior-posterior angulation, union and side effects. Follow-up visit and radiographs were taken 2 and 4 weeks as well as 3, 6 and 9 months after surgery. RESULTS: During the follow-up, 11 out of 60 patients in case and control groups were excluded. We recruited 24 and 25 patients in the case and control group, respectively. Intramedullary nailing was used in 8 patients of case and 11 patients of control group. Plate and screw were used in 16 patients in the case and 14 patients in the control group. Varus/valgus and anterior-posterior angulation were not statistically significant between two groups (P ≥ 0.05). The frequency of tibial and fibula union after 1, 3, 6 and 9 months in case and controls groups were not statistically significant (P ≥ 0.05). The frequency of nonunion of tibia and fibula, infection and nerve injury in studied groups were not statistically significant (P ≥ 0.05). CONCLUSION: We did not observe any significant improvement using fibular fixation in the treatment outcomes of tibia distal fractures.

Relationship between Bone Mineral Density and Serum Vitamin D with Low Energy Hip and Distal Radius Fractures: A Case-Control Study.

BACKGROUND: The main purpose of this study was to determine the relationship between serum vitamin D and the status of bone mineral density in patients with low-energy hip and distal radius fracture. METHODS: This retrospective case-control study was performed between January 2013 and January 2014. Participants aged 55 years or older were divided to case group including 85 patients with low-energy hip fracture and 83 patients with low-energy distal radius fractures, and 82 subjects as a matched control group. Bone mineral density was measured with dual energy X-ray absorptiometry and serum sample was obtained to check vitamin D, calcium, phosphorus, alkaline phosphatase, and protein. RESULTS: Study subjects for final evaluation consisted of 78 in hip and distal radius fracture groups and 80 in control group. There were no significant differences in the mean serum levels of calcium, phosphorus and alkaline phosphatase between the three groups. The overall mean serum level of vitamin D3 was significantly different among the three groups. Similar results were observed with hip and spine t-score between the groups. CONCLUSION: There is not only a direct relation between serum vitamin D and the risk of low energy hip and distal radius fractures, but also a significant relation between low bone density in hip and spine area with low serum calcium was observed.

Ultrasound guided platelet-rich plasma injection for the treatment of rotator cuff tendinopathy.

BACKGROUND: Degenerative changes and inflammation in the rotator cuff (RC) are the most important causes of shoulder pain. The aim of the present study was to determine the effectiveness of platelet-rich plasma (PRP) in patients with chronic RC tendinopathy. MATERIALS AND METHODS: This study was an open-label study performed at Kashani Hospital between April 2012 and June 2014. Patients with a <1 cm partial tearing of the bursal side of RC with no or little response to conservative management were included. PRP injection was done using ultrasonography guide via posterior subacromial approach. Demographic data were obtained in all patient before the study, and shoulder function was evaluated using Constant shoulder score (CSS) before and 3 months after PRP injection. RESULTS: A total number of 17 patients were enrolled. The mean of CSS before and after intervention was 37.05 ± 11.03 and 61.76 ± 14.75, respectively (P < 0.001). There was no statistically significant correlation between the pain score before the study and the improvement in CSS (P = 0.45, r = 0.03). Significant relation was observed between the individuals' age and improvement of CSS (P = 0.02, r = -0.49). There was no significant difference in CSS improvement between genders (P = 0.23). CONCLUSION: Single injection of PRP is effective to reduce pain and improve range of motion in patients with bursal side partial tearing of RC who failed to respond to conservative treatments.

Low Dose Perioperative Intravenous Tranexamic Acid in Patients Undergoing Total Knee Arthroplasty: A Double-Blind Randomized Placebo Controlled Clinical Trial.

Background and Objectives. The null hypothesis of this study was that TA has no effect on postsurgical bleeding in patients undergoing TKA. Methods. This study was a double-blind randomized trial. In the first group (T) patients received 500 mg of intravenous Tranexamic acid (TA) twice (once preoperatively and once 3 hours postoperatively) and in the second group (P) they received slow infusion of normal saline as placebo. The primary outcome of the study was the level of Hb 48 hours after surgery. Results. Hb levels 48 hours after surgery as the primary outcome were 10.92 ± 0.97 and 10.23 ± 0.98 (g/dL) in groups T and P, respectively, and the difference was statistically significant (P = 0.001). Statistically significant differences were also observed in Hb levels 6 and 24 hours after surgery, the drain output 48 hours after surgery, and the number of units of packed cells transfused between study groups (P < 0.05). There was no significant difference in duration of hospitalization between the study groups (P = n.s.). Conclusions. The low dose perioperative intravenous TA significantly reduces blood loss, requirement for blood transfusion, and drain output in patients undergoing TKA. However, duration of hospitalization did not change significantly.

Is there a place for open intramedullary nailing in femoral shaft fractures?

BACKGROUND: Femoral shaft fractures are among the most common fractures following high trauma injuries. Different kinds of treatment have been suggested for these injuries. AIM: The aim of this study was to compare the results femoral fractures treated by mini open and close intramedullary nailing (IMN) technique. MATERIALS AND METHODS: A total of 48 adult patients were operated due to fracture of the femur with close or open IMN technique between September 2010 and September 2011. 23 patients operated with close. IMN technique was included in Group I while 24 patients operated with mini open IMN technique constituted Group II. In Group I, all patients. Were operated on the fracture table in the supine position while in Group II, all patients underwent surgery on standard tables in the lateral position. RESULTS: The mean age of patients was 27.3 years, ranging between 16 and 62. The mean age of the close nailing and open nailing groups was 30.5 and 24.5 respectively (P = 0.052). Only one patient from the open nailing group failed to unite. The mean time for union in close and open nailing groups was 13 + 2.4 and 17.7 + 2.3 weeks respectively (P = 0.001). No infection or limb length discrepancies were observed in the two groups. CONCLUSION: Although close nailing is the preferred methods in most cases, but in poly-traumatized patients or in centers where there are no fracture tables or C-arm, open nailing is a good option.

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures.

BACKGROUND: Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.12 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture. MATERIALS AND METHODS: From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively. RESULTS: A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery. CONCLUSIONS: Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.

Comparison of functional outcomes of tibial plateau fractures treated with nonlocking and locking plate fixations: a nonrandomized clinical trial.

Fixation of tibial plateau fractures with plate has been widely used. This prospective study was planned to compare locking plate fixation of tibial plateau fracture with nonlocking methods in terms of their functional outcomes. The subjects of the study were selected from consecutive patients suffering from tibial plateau fractures referred to Kashani Hospital in Isfahan, Iran, between 2012 and 2013 and were candidate for surgery. The final included patients were assigned to two groups, those who were treated with locking plate (n = 20) and those who were treated with nonlocking plates (N = 21). The mean duration of follow-up was 13.4 months (ranging between 10 and 17 months). The mean of knee scores was significantly higher in locking plate group than in nonlocking plate group at the follow-up time (80.20 ± 10.21 versus 72.52 ± 14.75, P = 0.039). Also, the mean VAS pain severity score was significantly lower in locking plate group compared with nonlocking plate group (4.45 ± 2.50 versus 6.00 ± 2.59, P = 0.046). This study confirmed superiority of the locking plate method over nonlocking plate method with regard to knee score as well as VAS pain score.

Significance of the position of the proximal tip of the tibial nail: An important factor related to anterior knee pain.

BACKGROUND: Intramedullary nailing is the treatment of choice for the majority of tibial shaft fractures and anterior knee pain is the most common complication of this surgery; however, its etiology is still unknown. The purpose of this study was to assess the predicting factors related to anterior knee pain following tibial nailing. MATERIALS AND METHODS: Patients with isolated, unilateral tibial shaft fracture who had undergone tibial nailing were identified retrospectively. Data including age, sex, type of fracture, technique of surgery and location of the nail were collected and finally the association between the above variables and knee pain were analyzed via SPSS software. RESULTS: A total of 95 patients participated in the study. The mean age of the participants was 33.52 ± 1.62, 87 (91.6%) of whom were male and 74 (77.9%) had close fractures respectively. The method of surgery in 60 (63.2%) patients was paratendinous approach and in 35 (36.8%) was transtendinous. Twenty six (27.4%) of the patients had anterior knee pain. There were no significant differences between the two groups of patients with and without knee pain by age, sex, type of fracture and type of surgery (P = 0.952, 0.502, 0.212 and 0.745, respectively). Patients with protrusion of the nail from the anterior cortex had higher risk of developing knee pain after surgery (odds ratio: 2.76, confidence interval: 1.08, 7.08, P = 0.031). CONCLUSION: The results revealed a higher risk of developing anterior knee pain after tibial nailing in patients with protrusion of the nail from the anterior cortex.