European Journal of Cardiovascular Medicine

The most common long bone fractures are those of the tibia and fibula shafts. Tibial diaphyseal fractures represent the predominant category of tibial fractures. Fibular fractures occurred in 80% of these instances. [1]. Diaphyseal fractures of the adult tibia predominantly occurred in young males aged 15 to 19 years, with an annual incidence rate of 109 per 100,000 individuals. Tibia diaphyseal fractures in adults predominantly occurred in women aged 90 to 99 years, with a yearly incidence of 49 per 1,000 individuals [2]. Diaphyseal tibia fractures exhibit a notable risk of non-union, while malunion of tibial shaft fractures demonstrates a bimodal distribution: low-energy spiral fractures are prevalent in individuals over 50 years, whereas high-energy transverse and comminuted fractures are more frequent in patients under 30. Falls from a standing position and sports-related injuries are the primary causes of low-energy tibial fractures, while vehicular trauma is the predominant cause of high-energy tibial diaphyseal fractures [1]. In the adult demographic, intramedullary nail fixation is the preferred intervention for displaced and unstable tibial shaft fractures. Intramedullary nail fixation offers the benefit of necessitating minimum surgical dissection while maintaining the fracture's extraosseous blood supply. Intramedullary nail fixation was primarily restricted to fractures of the proximal and distal metaphysis. The conventional infrapatellar approach for tibial intramedullary nailing is a recognized surgical technique for addressing tibial shaft fractures. Nevertheless, the force of the quadriceps muscle can lead to proximal fracture fragment displacement when the knee is flexed, increasing the risk of valgus and procurvatum deformities after tibial nailing; hence, intramedullary nail insertion via the infrapatellar route presents challenges [3]. Recent advancements in nail design and reduction techniques have broadened the parameters for intramedullary nail fixation to encompass both proximal and distal tibial fractures, including the metaphyseal region. Suprapatellar nailing in the semi-extended position has recently been advocated as a safe and effective surgical intervention. The method facilitates the selection of an appropriate initial position in a semi-extended posture, which assists in fracture reduction, especially in apex anterior abnormalities. Initial clinical data indicate favorable outcomes, featuring a minimal incidence of post-procedural knee discomfort [4]. As there were only a few studies [5-9] done in the past on this topic hence, the present study was conducted with an aim to compare the clinical and functional outcomes of tibial shaft fractures treated with intramedullary nailing (IMN) utilising the SP and IP methods.

A prospective interventional study was carried out in the Department of Orthopaedics at Indira Gandhi Institute of Medical Sciences, Patna, Bihar (India). Prior to participation, informed consent was obtained from all subjects. The study included patients with tibial shaft fractures who presented during the study period. They were divided into two groups: Group A patients underwent intramedullary nailing (IMN) of the tibia using the suprapatellar (SP) approach, while Group B patients were treated using the infrapatellar (IP) approach. Allocation to each group was done using an alternating sequence based on odd and even registration numbers. A total of 40 cases were enrolled, and fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system [10].

Inclusion Criteria:

Patients aged >18 to <65 years with closed fractures of the tibial and fibular shafts; open fractures of both bones of the leg up to Gustilo-Anderson grade 3A [11]; segmental tibial fractures; proximal and distal third tibial shaft fractures; all diaphyseal tibial fractures; and those medically fit for surgery.

Exclusion Criteria:

Patients aged <18 years; open fractures classified as Gustilo-Anderson grade 3B or 3C [11]; neglected or old shaft tibial fractures; fractures with intra-articular extension; and cases with an intramedullary canal diameter less than 7 mm.

Study Procedure:

Surgical approach: In the present study, tibial shaft fractures were fixed with an intramedullary nail (IMN) via midline patellar tendon split infra-patellar (IP) and supra-patellar (SP) approach [Table 1].

Table 1: Showing the overview of the supra-patellar (SP) and infra-patellar (IP) approach

Standard surgical technique of Intra Medullary Nail (IML) insertion: A nail was inserted over the guide wire from the entrance point created on the exposed region of the tibia, following provisional reduction using manipulation and traction.

Postoperative protocol: Intravenous antibiotics (second-generation cephalosporins and aminoglycosides) were supplied for two days, and on postoperative day one, passive and active range of motion exercises for the knee and ankle joints were permitted.  Partial weight bearing was permitted at six weeks, and upon the observation of fracture healing on X-rays, full weight bearing was authorized.

Follow-up: Post-surgery, patients were monitored at six weeks, three months, and six months intervals. During each follow-up, serial anteroposterior and lateral X-ray pictures were obtained, and the patient was evaluated for radiological and clinical indicators of union. The Lower Extremity Functional Scale [12] was employed to evaluate the functional outcome. The functional outcomes of intramedullary nailing (IMN) for tibial shaft fractures using the suprapatellar (SP) and infrapatellar (IP) approaches were evaluated based on fluoroscopy duration, mean surgical duration, anterior knee pain (Visual Analog Scale score), average blood loss, fracture union time, and lower extremity functional score outcomes. The highest possible score for 20 associated daily activities was 80. Each activity was allocated a maximum of four points. A score of 70-80 indicated an exceptional functional outcome. A score of 60-70 signifies a favorable functional outcome. A score of 40-60 indicated a satisfactory functional outcome. A score below 40 resulted in an unfavorable functional outcome [13].

Functional definitions:

• Average blood loss: The average blood loss that occurs during the time of surgery.
• Anterior knee pain: Pain that occurs in the anterior and central aspect of the knee. It was measured using the VAS scale [13].
• Fracture union time: Time duration from the surgery to the union, which is calculated by the functional outcome score [12].

Statistical Analysis: The findings were tabulated and analyzed statistically by using the GraphPad Prism version 9 software. The obtained data is expressed in terms of Mean and standard deviation. The student’s t-test and the Chi-square test were used to compare the outcomes between the groups. A p-value less than 0.05 was considered significant in this study for the analysis.

The socio-demographic parameters of study participants are shown in Table 2. There were no statistically significant differences between Group A (Suprapatellar approach) and Group B (Infrapatellar approach) in terms of age, sex distribution, or fracture classification. This indicates that both groups were well-matched at baseline, ensuring that any differences in clinical or functional outcomes observed in the study can be attributed to the surgical approach rather than demographic or fracture pattern variations.

The average surgical time in Group A (Suprapatellar approach) was 88.65 ± 11.35 minutes, compared to 93.43 ± 8.97 minutes in Group B (Infrapatellar approach). Although the suprapatellar approach showed a slightly shorter operative duration, the difference was not statistically significant (p = 0.213). This suggests that both approaches are comparable in terms of surgical time, and neither technique offers a distinct advantage in this regard (Table 3).

The average intraoperative blood loss was significantly lower in Group A (Suprapatellar approach; 48.76 ± 12.75 mL) compared to Group B (Infrapatellar approach; 63.89 ± 7.43 mL), with a statistically significant difference (p = 0.002). This finding suggests that the suprapatellar approach may offer an advantage in minimizing blood loss during intramedullary nailing of tibial shaft fractures (Table 4).

The fluoroscopy time was significantly shorter in Group A compared to Group B, with a highly statistically significant difference (p = 0.002) (Table 5). This demonstrates that the suprapatellar approach requires substantially less intraoperative radiation exposure for both the patient and surgical team. The reduced fluoroscopy time in the suprapatellar group likely reflects the more direct and unobstructed path for nail insertion, allowing for easier fracture reduction and guidewire placement. This advantage not only improves surgical efficiency but also minimizes radiation-related risks, making the suprapatellar approach a potentially safer option in terms of occupational hazards and long-term radiation exposure.

We observed a statistically significant difference (p = 0.002) in postoperative knee pain between the two surgical approaches, as measured by the Visual Analog Scale (VAS). Patients in Group A (Suprapatellar approach) reported substantially lower pain scores (18.45 ± 3.43) compared to those in Group B (Infrapatellar approach; 28.77 ± 2.86) (Table 6).

The mean fracture healing time was comparable between the two groups, with Group A (suprapatellar approach) showing 89.34±3.19 days and Group B (infrapatellar approach) showing 89.19±2.74 days. The difference was not statistically significant (p = 0.598), indicating similar bone union rates regardless of the surgical approach (Table 7).

The suprapatellar approach (Group A) demonstrated significantly better postoperative lower extremity function scores (76.67 ± 2.87) compared to the infrapatellar approach (Group B, 71.59 ± 2.98), with this difference being statistically significant (p = 0.001). These findings indicate superior functional recovery when using the suprapatellar technique for intramedullary nailing of tibial shaft fractures (Table 8).

Table 2: Showing the socio-demographic parameters of the study participants

Table 3: Showing the average surgical time (minutes) in the study participants

Table 4: Showing the average blood loss (mL) during surgery in the study participants

Table 5: Showing the fluoroscopy time in the study participants

Table 6: Showing the average knee pain (VAS) in the study participants

Table 7: Showing the fracture healing time in the study participants

Table 8: Showing the lower extremity function score in the study participants

Intramedullary nailing (IMN) is gaining popularity as a treatment for tibia fractures due to its less stress on surrounding soft tissues, reduced likelihood of malunion, and enhanced biomechanical strength. The conventional infrapatellar (IP) technique and the suprapatellar (SP) approach in a semi-extended posture are employed for intramedullary nailing (IMN) insertion [11]. The average surgical duration was comparable in both groups, consistent with the findings of Wang C et al. [11], who demonstrated a decrease in fluoroscopy time while preserving the overall operational duration. Ponugoti N et al. [14] conducted a meta-analysis comparing suprapatellar and infrapatellar approaches and found comparable results. In a meta-analysis comparing suprapatellar (SP) and infrapatellar (IP) intramedullary nailing (IMN), Xu H et al. [15] determined that the suprapatellar method resulted in decreased fluoroscopy time. This may result from the semi-extended position, which facilitates leg manipulation and access to the fluoroscopic image intensifier during the procedure [16]. Packer TW et al. reached analogous outcomes in their study. The widespread utilization of intraoperative fluoroscopy exposes orthopedic teams to elevated radiation exposures, hence increasing the risk of thyroid cancer [17]. Consequently, the suprapatellar technique is effective in mitigating this risk for both the surgeon and the patient.

The infrapatellar approach using the intramedullary nailing (IMN) technique resulted in increased average blood loss. These findings aligned with those of Yang L et al., who reported similar results in their study [18]. Minimizing perioperative blood loss was a critical concern that facilitated recovery and reduced the necessity for blood transfusions. The VAS pain score in the suprapatellar (SP) group was significantly lower than that in the IP group, as indicated by the current study. This finding aligns with that of MacDonald DRW et al., [19], who assessed VAS scores between the infrapatellar (IP) and suprapatellar (SP) procedures in 95 patients, revealing that intramedullary nailing (IMN) via the suprapatellar (SP) approach is associated with reduced postoperative anterior knee discomfort compared to the infrapatellar (IP) approach [19]. The splitting of the patellar tendon, which affects the infrapatellar nerve and produces intra-articular structural damage, are all contributors to postoperative knee pain that the suprapatellar approach seeks to mitigate [15]. Yang L et al.'s [18] meta-analysis indicated that the suprapatellar (SP) technique was associated with a significant reduction in VAS scores.

The mean duration of fracture healing was similar for the suprapatellar (SP) and infrapatellar (IP) intramedullary nailing (IMN) techniques in this investigation. The findings were analogous to those of Chen X et al. [5], who observed no significant disparity in fracture union time between the two cohorts. Postoperative anterior knee discomfort was significantly diminished in the suprapatellar (SP) group due to early rehabilitation, resulting in a higher lower extremity functional score for the SP group. The results align with those of Gao Z et al. [6] and Ponugoti N et al. [14]. A study by Lu Y et al. [7] indicated that the malalignment rate in the SP group was 4.8%, much lower than the 14.3% observed in the infrapatellar (IP) group, consistent with the index study. Furthermore, Stella M et al. discovered that the infrapatellar (IP) cohort exhibited a 26.1% prevalence of angular deformity [20]. In the infrapatellar (IP) group, the quadriceps' tension induced flexion of the proximal fragment, leading to procurvatum and valgus deformity. The suprapatellar (SP) technique, with the knee joint positioned in semi-flexion (10-30°), facilitated quadriceps relaxation and directed the nail to an optimal starting point, thereby eliminating the obstructing influence of the patella. All these factors contribute to a reduction in deformity rates. It is recommended that a study be undertaken with a larger sample size to generalize the findings.

The suprapatellar (SP) technique yielded superior functional outcomes, reduced pain, diminished fluoroscopy duration and radiation exposure, and a lower mean total blood loss compared to the infrapatellar (IP) method. Consequently, intramedullary nailing (IMN) using the suprapatellar (SP) technique is considered the most effective treatment for tibial shaft fractures.

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