A comparison of anterior knee pain, kneeling pain and functional outcomes in suprapatellar versus infrapatellar tibial nailing.

INTRODUCTION: Anterior knee pain and kneeling pain are some of the most common complications following intramedullary nailing of tibial shaft fractures. With the increased uptake of suprapatellar nailing at our institution, we undertook a service evaluation to assess anterior knee pain and kneeling pain in patients who underwent the suprapatellar tibial nailing technique compared with the infrapatellar approach. METHODOLOGY: Data from all consecutive intramedullary tibial nailing operations between January 2014 and July 2017 were analysed from a prospectively collected database. All acute diaphyseal fracture nailing procedures were included. All patients were reviewed between six-month and four-year post-operation. Each patient was asked to complete a standardised questionnaire with three main outcome measures: pain on kneeling, presence of anterior knee pain and the severity of pain. RESULTS: After exclusions, a total of 148 patients were identified. A total of 102 responses were received, 41 in the infrapatellar group (73.2%) and 61 in the suprapatellar group (66.3%). A longer time from surgery to telephone follow-up response was noted in the infrapatellar group: 32.4 months (interquartile range, 16.1) vs. 19.3 months (interquartile range, 17.4), p < 0.001. A trend towards lower reported anterior knee pain was noted in the suprapatellar group (67.9% VS 53.7%). Most patients reported mild or no pain on kneeling, with no significant difference between the two groups. There was also no significant difference in severity of knee pain between the two groups and no significant effect on the Kujala score. CONCLUSION: With the comparable pain outcomes between the two groups, our analysis supports the continued use of the suprapatellar tibial nailing technique for tibial shaft fractures at our institution.

Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study.

Distal femur fractures are rare injuries with a bimodal distribution (high-energy injury in young males and low-energy fragility fractures in old females). Their management can be challenging: open reduction and internal fixation (ORIF) with distal femur locking plates is a commonly performed procedure especially in comminuted fractures with articular involvement. Anxiety regarding the stability of the fixation, especially in osteoporotic bone, leads to post-operative restrictive instructions with limitations regarding the weight-bearing status. Early weight bearing (EWB), however, was shown to enhance bone healing and was not correlated with an increased risk of fracture displacement or implant failure in previous published studies, which reported the results of proximal femur, tibia and ankle fractures surgical treatment. The current study analysed the results of a series of distal femur fractures (51 patients, mean age 64.3 ± 20.7) all treated with ORIF in a level-I major trauma centre, but differently rehabilitated. Group A was, in fact, instructed not to weight bear or to touch weight bear, while group B started to weight bear soon after surgery without specific restrictions. The objective was to compare the outcome and the complication rate in the two groups at 6 and 12 weeks after surgery. The results showed no statistically significant differences in the two groups and no post-operative complications in the EWB group. Six complications were observed in the non-weight-bearing group (four fractures displacement and two implants failure at 12-week follow-up). Distal femur fractures treated with locking plates can be rehabilitated with EWB to allow early return to function. There is no evidence that EWB increases the risk of fracture displacement or implant failure in distal femur fractures treated with distal locking plates. Instead, it is possible that post-operative non-weight-bearing status delays the fracture-healing process increasing the risk of failure of the fixation.