Scientific Article   |    
Anterior Knee Pain After Intramedullary Nailing of Fractures of the Tibial Shaft A Prospective, Randomized Study Comparing Two Different Nail-Insertion Techniques
Jarmo A.K. Toivanen, MD, PhD; Olli V�ist�, BM; Pekka Kannus, MD, PhD; Ky�sti Latvala, MD; Seppo E. Honkonen, MD, PhD; Markku J. J�rvinen, MD, PhD
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Investigation performed at the Tampere University Hospital, University of Tampere, Tampere, Finland

Jarmo A.K. Toivanen, MD, PhD
Olli V�ist�, BM
Pekka Kannus, MD, PhD
Ky�sti Latvala, MD
Seppo E. Honkonen, MD, PhD
Markku J. J�rvinen, MD, PhD
Department of Physiotherapy (K.L.) and Division of Orthopaedics and Traumatology, Department of Surgery (J.A.K.T., O.V., P.K., S.E.H., and M.J.J.), Tampere University Hospital, Medical School, K-building, FIN-33014 University of Tampere, Finland. E-mail address for J.A.K. Toivanen: jarmo.toivanen@uta.fi

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2002 Apr 01;84(4):580-585
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Background: 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 portal.

Methods: 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.

Results: 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.

Conclusion: 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.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Posted on April 11, 2002
    Other factors influencing results

    I would like to congratulate you for this research. I would add that other important factors that influence healing in addition to the entry point of the nail include the type of fracture (open or closed) and the type of energy that caused the injury. If the results had been analyzed according to these variables, the results reported by the authors might have been different. The elapsed time for fracture healing and the rehabilitation program would have been quite different in each group and this would affect the weight bearing and tendon healing time. So far we have treated more than 200 closed and/or open tibial fractures by means of intramedullary nail. Our primary concern is not the anterior knee pain but the elapsed time for fracture healing.

    Kaan Erler MD
    Assoc Prof
    Gulhane Mil Med Acad
    Department of Orthopaedics

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