Anterior knee pain is the most common complication after intramedullary
nailing of the tibia. Dissection of the patellar tendon and its
sheath during nailing is thought to be a contributing cause of chronic
anterior knee pain. The purpose of this prospective, randomized
study was to assess whether the prevalence or the intensity of anterior
knee pain following intramedullary nailing of a tibial shaft fracture
is reduced by the use of a paratendinous incision for the nail entry
Fifty patients with a tibial shaft fracture requiring intramedullary
nailing were randomized equally to treatment with paratendinous
or transtendinous nailing. Twenty-one patients from both study groups
were followed for an average of three years after nailing. After
fracture union, all but two patients had elective nail removal through
the same surgical approach as was used for the nailing. At the follow-up
evaluation, the patients used visual analog scales to report their
level of anterior knee pain and the impairment caused by that pain.
The scales described by Lysholm and Gillquist and by Tegner et al.,
the Iowa knee scoring system, and simple functional tests were used
to quantitate the functional results. Isokinetic thigh-muscle strength
was also measured.
Fourteen (67%) of the twenty-one patients treated with transtendinous
nailing reported anterior knee pain at the final evaluation. Of
these fourteen patients, thirteen were mildly to severely impaired
by the pain. Fifteen (71%) of the twenty-one patients treated with
paratendinous nailing reported anterior knee pain, and ten of the
fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa
knee scoring systems; muscle-strength measurements; and functional
tests showed no significant differences between the two groups.
Compared with a transpatellar tendon approach, a paratendinous
approach for nail insertion does not reduce the prevalence of chronic
anterior knee pain or functional impairment by a clinically relevant
amount after intramedullary nailing of a tibial shaft fracture.