Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Gang ¹ , ZHANG Lecheng ¹ , YAN Chao ¹ , YUAN Ying ² , LÜ Shengsong ¹ ,  ZHANG Yuelei ¹

1. Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230000, P.R.China;
2. Sanxiaokou Street Community Health Service Center of Luyang District, Hefei Anhui, 230000, P.R.China;

Corresponding author：

ZHANG Yuelei, Email: orthozhang5233@163.com

Keywords：

Tibial shaft fracture; extraarticular parapatellar approach; intramedullary nailing; internal fixation

DOI：

10.7507/1002-1892.202006030

Video：

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Objective To investigate the effectiveness of intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach for tibial shaft fracture.Methods Between July 2018 and September 2019, 22 patients with tibial shaft fracture treated with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach. There were 15 males and 7 females, with an average age of 46.4 years (range, 25-68 years). The fractures were caused by falling in 7 cases, by traffic accident in 14 cases, and by a heavy object in 1 case. Sixteen patients were closed fractures and 6 were open fractures. According to the AO classification, there were 4 cases of 42-A1 type, 2 cases of 42-A2 type, 3 cases of 42-A3 type, 3 cases of 42-B2 type, 4 cases of 42-B3 type, 2 cases of 42-C1 type, 3 cases of 42-C2 type, and 1 case of 42-C3 type. Twenty cases complicated with fibular fractures. The time from injury to operation was 2-15 days (mean, 7.5 days). The fracture healing time, complications, the incidence of anterior knee pain during the follow-up were observed; and knee joint functions were evaluated by Lysholm score at last follow-up.Results The operation time was 50-140 minutes (mean, 85 minutes). Two cases experienced incision exudation which healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 8-23 months (mean, 14.9 months). X-ray films reexamination showed that all fractures healed with the healing time of 12-20 weeks (mean, 14.4 weeks). Four patients (18.18%) experienced the anterior knee pain. No patellofemoral instability was observed during the follow-up period. Lysholm score of knee function was 85-100 (mean, 94.3) at last follow-up. Conclusion Application of the intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach is effective for tibial shaft fractures, which can not only realize the effective fixation of the fracture, but also avoid the adverse factors including re-displacement and anterior knee pain in the application of the intramedullary nailing fixation via the sub-patellar approach.

Citation： WANG Gang, ZHANG Lecheng, YAN Chao, YUAN Ying, LÜ Shengsong, ZHANG Yuelei. Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(12): 1574-1578. doi: 10.7507/1002-1892.202006030 Copy

1.	高伟, 李夏, 高堪达, 等. 经髌上入路锁定型胫骨髓内钉在胫骨干多节段骨折治疗中的应用. 中华创伤骨科杂志, 2018, 20(2): 167-171.
2.	Laigle M, Rony L, Pinet R, et al. Intramedullary nailing for adult open tibial shaft fracture. An 85-case series. Orthop Traumatol Surg Res, 2019, 105(5): 1021-1024.
3.	Wang B, Zhao Y, Wang Q, et al. Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis. J Orthop Surg Res, 2019, 14(1): 456.
4.	Cazzato G, Saccomanno MF, Noia G, et al. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series. Injury, 2018, 49 Suppl 3: S61-S64.
5.	Zelle BA. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar portal technique. Int Orthop, 2017, 41(9): 1909-1914.
6.	Yasuda T, Obara S, Hayashi J, et al. Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: evaluation of the patellofemoral joint. Injury, 2017, 48(6): 1264-1268.
7.	Tornetta P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res, 1996, (328): 185-189.
8.	Kubiak EN, Widmer BJ, Horwitz DS. Extra-articular technique for semiextended tibial nailing. J Orthop Trauma, 2010, 24(11): 704-708.
9.	Stella M, Santolini E, Felli L, et al. Semiextended tibial nail insertion using an extraarticular lateral parapatellar approach: a 24-month follow-up prospective cohort study. J Orthop Trauma, 2019, 33(10): e366-e371.
10.	Zamora R, Wright C, Short A, et al. Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study. Injury, 2016, 47(10): 2087-2090.
11.	Samuelson MA, McPherson EJ, Norris L. Anatomic assessment of the proper insertion site for a tibial intramedullary nail. J Orthop Trauma, 2002, 16(1): 23-25.
12.	Wu CC, Wong YC. Identifying the optimal inlet for antegrade tibial intramedullary nailing via magnetic resonance imaging. Injury, 2019, 50(11): 2065-2069.
13.	Bishop JA, Campbell ST, Eno JT, et al. Knee pain after intramedullary nailing of tibia fractures: prevalence, etiology, and treatment. J Am Acad Orthop Surg, 2018, 26(18): e381-e387.
14.	Väistö O, Toivanen J, Kannus P, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma, 2008, 64(6): 1511-1516.
15.	Wang C, Chen E, Ye C, et al. Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: a meta-analysis. Int J Surg, 2018, 51: 133-139.
16.	Busel GA, Mir H. Suprapatellar tibial nailing. Orthop Clin North Am, 2019, 50(3): 289-295.
17.	Weninger P, Schultz A, Traxler H, et al. Anatomical assessment of the Hoffa fat pad during insertion of a tibial intramedullary nail—comparison of three surgical approaches. J Trauma, 2009, 66(4): 1140-1145.
18.	Weil YA, Gardner MJ, Boraiah S, et al. Anterior knee pain following the lateral parapatellar approach for tibial nailing. Arch Orthop Trauma Surg, 2009, 129(6): 773-777.
19.	Jankovic A, Korac Z, Bozic NB, et al. Influence of knee flexion and atraumatic mobilisation of infrapatellar fat pad on incidence and severity of anterior knee pain after tibial nailing. Injury, 2013, 43 (Suppl 3): S33-S39.
20.	Rothberg DL, Daubs GM, Horwitz DS, et al. One-year postoperative knee pain in patients with semi-extended tibial nailing versus control group. Orthopedics, 2013, 36(5): e548-e553.
21.	Bakhsh WR, Cherney SM, McAndrew CM, et al. Surgical approaches to intramedullary nailing of the tibia: comparative analysis of knee pain and functional outcomes. Injury, 2016, 47(4): 958-961.
22.	Hessmann MH, Buhl M, Finkemeier C, et al. Suprapatellar nailing of fractures of the tibia. Oper Orthop Traumatol, 2020. [Epub ahead of print].

1. 高伟, 李夏, 高堪达, 等. 经髌上入路锁定型胫骨髓内钉在胫骨干多节段骨折治疗中的应用. 中华创伤骨科杂志, 2018, 20(2): 167-171.
2. Laigle M, Rony L, Pinet R, et al. Intramedullary nailing for adult open tibial shaft fracture. An 85-case series. Orthop Traumatol Surg Res, 2019, 105(5): 1021-1024.
3. Wang B, Zhao Y, Wang Q, et al. Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis. J Orthop Surg Res, 2019, 14(1): 456.
4. Cazzato G, Saccomanno MF, Noia G, et al. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series. Injury, 2018, 49 Suppl 3: S61-S64.
5. Zelle BA. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar portal technique. Int Orthop, 2017, 41(9): 1909-1914.
6. Yasuda T, Obara S, Hayashi J, et al. Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: evaluation of the patellofemoral joint. Injury, 2017, 48(6): 1264-1268.
7. Tornetta P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res, 1996, (328): 185-189.
8. Kubiak EN, Widmer BJ, Horwitz DS. Extra-articular technique for semiextended tibial nailing. J Orthop Trauma, 2010, 24(11): 704-708.
9. Stella M, Santolini E, Felli L, et al. Semiextended tibial nail insertion using an extraarticular lateral parapatellar approach: a 24-month follow-up prospective cohort study. J Orthop Trauma, 2019, 33(10): e366-e371.
10. Zamora R, Wright C, Short A, et al. Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study. Injury, 2016, 47(10): 2087-2090.
11. Samuelson MA, McPherson EJ, Norris L. Anatomic assessment of the proper insertion site for a tibial intramedullary nail. J Orthop Trauma, 2002, 16(1): 23-25.
12. Wu CC, Wong YC. Identifying the optimal inlet for antegrade tibial intramedullary nailing via magnetic resonance imaging. Injury, 2019, 50(11): 2065-2069.
13. Bishop JA, Campbell ST, Eno JT, et al. Knee pain after intramedullary nailing of tibia fractures: prevalence, etiology, and treatment. J Am Acad Orthop Surg, 2018, 26(18): e381-e387.
14. Väistö O, Toivanen J, Kannus P, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma, 2008, 64(6): 1511-1516.
15. Wang C, Chen E, Ye C, et al. Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: a meta-analysis. Int J Surg, 2018, 51: 133-139.
16. Busel GA, Mir H. Suprapatellar tibial nailing. Orthop Clin North Am, 2019, 50(3): 289-295.
17. Weninger P, Schultz A, Traxler H, et al. Anatomical assessment of the Hoffa fat pad during insertion of a tibial intramedullary nail—comparison of three surgical approaches. J Trauma, 2009, 66(4): 1140-1145.
18. Weil YA, Gardner MJ, Boraiah S, et al. Anterior knee pain following the lateral parapatellar approach for tibial nailing. Arch Orthop Trauma Surg, 2009, 129(6): 773-777.
19. Jankovic A, Korac Z, Bozic NB, et al. Influence of knee flexion and atraumatic mobilisation of infrapatellar fat pad on incidence and severity of anterior knee pain after tibial nailing. Injury, 2013, 43 (Suppl 3): S33-S39.
20. Rothberg DL, Daubs GM, Horwitz DS, et al. One-year postoperative knee pain in patients with semi-extended tibial nailing versus control group. Orthopedics, 2013, 36(5): e548-e553.
21. Bakhsh WR, Cherney SM, McAndrew CM, et al. Surgical approaches to intramedullary nailing of the tibia: comparative analysis of knee pain and functional outcomes. Injury, 2016, 47(4): 958-961.
22. Hessmann MH, Buhl M, Finkemeier C, et al. Suprapatellar nailing of fractures of the tibia. Oper Orthop Traumatol, 2020. [Epub ahead of print].

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach

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