Advances in Intramedullary Nailing: Suprapatellar Nailing of Tibial Shaft Fractures in the Semiextended Position

Abstract

Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that allows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggested that this technique is associated with a low rate of complications, including a reduced incidence of postoperative anterior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes.

Suprapatellar versus infrapatellar intramedullary nailing for treatment of tibial shaft fractures in adults

“…Alternatively, all of these effects may be avoided by using the SP approach. It reduces injury to the patellar ligament by splitting the quadriceps tendon, and the lower knee flexion (approximately 15°) [ 32 ] avoids damage to articular cartilage, meniscus, and the inferior pole of patella. [ 33 ]…”

Use of the suprapatellar approach in intramedullary nailing of a multi-fragmentary dislocated tibia fracture with a hypermobile intermediate fragment in a young patient

“…Regarding the young age of our patient, the high functional requirements and the demand for temporary recovery we employed the intramedullary nailing of the tibia, in order to provide minimal surgical dissection and preservation of the extraosseous blood supply. 5 To prevent malformation due to hypermobile intermediate fragment we decided in favor of the suprapatellar approach in the semiextended position.…”

“…Caregivers remain concerned about the transarticular nail insertion regarding associated injuries to the patellofemoral cartilage and the long-term consequences associated with this. 5 Gelbke et al . showed in human cadaver specimens that despite increased intraarticular pressure during the suprapatellar approach the maximum pressure stayed well below the pressure at which apoptosis of chondrocytes occur.…”

“…8 Here nailing in the semiextended position provides several advantages. It has been reported to facilitate fracture reduction by reducing the apex anterior angulation by eliminating the extension force of the quadriceps, 5 especially desirable in fractures with a hypermobile intermediate fragment. Another favorable aspect of the suprapatellar approach has been reported by Sanders et al .…”

“…Caregivers may remain reluctant to implement this novel, innovative technique due to concerns regarding iatrogenic damage to the patellofemoral joint especially in young patients. 5 Further prospective clinical studies are necessary to evaluate the impact of the suprapatellar approach on anterior knee pain, damage to the patellofemoral joint functional outcome of the knee.…”