Summary

Our systematic review found limited current clinical evidence to support the use of suprapatellar or retropatellar approach in performing tibial intramedullary nailing for diaphyseal fracture.

Abstract

Introduction

Conventional infrapatellar approach with deep flexion of the knee during tibial intramedullary nail insertion is thought to contribute to post-operative anterior knee pain. An alternative approach, where the tibial nail is inserted through a suprapatella portal had been described, with avoidance of damage to the patella tendon as one of the proposed benefit, but with a potential risk of injury to the patellofemoral articular surfaces.

The aim of this systematic review is to assess current clinical evidence on the risks and benefits of the suprapatellar approach in the treatment of tibial diaphyseal fractures.

Methods

A literature search was performed on electronic databases including PubMed, MEDLINE, EMBASE and AMED, from their inception to 14th January 2016, using MeSH terms and Boolean operators for journal articles related to “intramedullary fracture fixation”, “fracture, tibial”, and keywords includings “suprapatella*”, “retropatella*”, and “semi-extended”, with no search limit applied.

All in vivo studies reporting treatment outcomes following intramedullary fixation, and using suprapatellar approach for the management of extra-articular tibial diaphyseal fractures, were included. Similarly, ex vivo studies reporting damages to structures or complications using cadaveric limbs were also included.

Studies were excluded if they did not fulfill the above criteria.

Results

A total of 27 citations were found after removal of 41 duplications. Further 3 citations were excluded after screening of titles and abstracts.

Of the 24 articles, 3 in vivo studies were found reporting treatment outcome following intramedullary nailing of the tibia using a suprapatellar approach. Another 5 ex vivo studies were found to report potential risks and complications to the regional anatomy following the procedure. These studies were included in this systematic review.

There was a total of 80 patients from in vivo studies. Fracture reduction was found to be satisfactory in all reported cases, and fracture union was also found to be satisfactory where reported. There was no reported difference in outcome between retropatellar and infrapatella approach. Poor outcomes appeared to be associated with patients who had polytrauma.

From the 5 ex vivo studies, there were 59 and 28 specimens treated with retropatellar and infrapatellar nailing respectively. Articular damages were reported in 2 studies where medial articular injury was found in 3 out of 31 specimens. Retropatellar articular contact pressure was reported in one study, and found higher pressure exerted on the articular cartilage in suprapatellar techinque compared to infrapatellar approach. Bone loss at the entry point was also found to be higher in suprapatellar approach where it was reported in a single study.

Conclusion

There was limited current clinical evidence to support the use of suprapatellar or retropatellar approach in performing tibial intramedullary nailing for diaphyseal fracture. Amongst the available clinical evidence, these are of low quality. Further studies are needed, with more robust study design, where these proposed techniques are compared with the conventional approach.