Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis

Abstract

Background This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing. Method This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data. Results Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: − 15.14 min, 95% CI − 21.28 to − 9.00). Conclusions With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures. Level of evidence: Level III, systematic review of non-randomized studies.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach

“…Since the implementation of SP IMN into the treatment protocol of tibial fractures at our hospital, peri- or postoperative fasciotomies have not been required. To our knowledge, some benefits of using SP approach have been reported, but no previous studies are concerning ACS and the need for fasciotomies in relation to the nailing technique chosen [ 19 , 25 – 30 ].…”

“…Previously, fasciotomies might not have been considered as a complication of a surgical method but rather a treatment of compartment syndrome resulting from the fracture itself. To date, only a few studies have reported the rates of fasciotomies in association to the treatment of tibial fractures using an intramedullary nail [ 25 , 32 – 34 ]. ACS and fasciotomies after tibial fracture are associated with a higher risk for complications, slower fracture healing, and poor functional outcomes [ 3 , 7 , 10 , 18 , 25 ].…”

“…To date, only a few studies have reported the rates of fasciotomies in association to the treatment of tibial fractures using an intramedullary nail [ 25 , 32 – 34 ]. ACS and fasciotomies after tibial fracture are associated with a higher risk for complications, slower fracture healing, and poor functional outcomes [ 3 , 7 , 10 , 18 , 25 ]. Therefore, the suprapatellar approach can be recommended for reducing the rates of peri- and postoperative compartment syndrome requiring fasciotomies.…”

“…Therefore, the suprapatellar approach can be recommended for reducing the rates of peri- and postoperative compartment syndrome requiring fasciotomies. Moreover, the use of the suprapatellar approach should lead to both a decrease in the morbidity associated with fasciotomies and better functional outcomes [ 19 , 25 – 31 ].…”

“…According to recent studies and a meta-analysis, SP IMN has multiple advantages compared with IP IMN [ 25 ]. These advantages include shorter fluoroscopy time, less anterior knee pain, better or similar recovery of knee function, and more accurate fracture reduction compared with the IP technique [ 16 , 19 , 25 – 30 ]. However, surgical time, blood loss, knee infection rate, nonunion rate, and closed reduction rate do not seem to differ significantly [ 19 , 25 – 31 ].…”